Complaint Investigation Report

On 02/04/2025, LPA attempted to interview two (2) of the three (3) clients; however, Client #1 (C1) and Client #2 (C2) did not respond to the LPA’s questions due to their limited verbal communication ability. From approximately 12:50 p.m. to 2:30 p.m., LPA interviewed Client #3 (C3), eight (8) staff members, and the licensee. During the visit on 08/04/2025, from approximately 12:05 p.m. to 12:30 p.m., LPA interviewed the administrator and Client #2 (C2). On 10/06/2025 LPA Rios requested a copy of the Corrective Action (CAP) developed by North Los Angeles County Regional Center and the facility.

On initial visit LPA Rios did not observe serious injuries to C1 and was not able to determine if injuries on C1 were self inflicted or not. LPA’s interview with C3 supported the allegation stating that S1 had been rough with them as well. C1 did not provide any specific information regarding S1's treatment of C1 and C2. Interview with two (2) out of eight (8) staff corroborate the allegation. Although neither staff member reported witnessing S1 take C1 to the ground, one (1) staff member stated they had observed S1 being rough with C1, and another reported witnessing S1 press their elbows into C1’s back and antagonize clients to provoke arguments among them. Both staff members acknowledged they did not report these incidents to the administrator or licensee. One (1) stating they were never asked, and the other stating they did not realize that the restraint or hold used was inconsistent with CPI training until receiving additional training. Interview with the administrator and Licensee denied they had witnessed S1 or other staff mistreat clients and denied receiving allegations regarding S1’s treatment of C1. LPAs interview with C2 revealed they witnessed a client be brought down to the floor and held on the ground. C2 did not provide specific information about who was involved and when they witnessed the incident only that it was protect them from the client. Review of CAP revealed NLACRC interviewed a staff that witnessed S1 grab C1 by their hands and lay on C1, slapping C1's arms and head. C1. Review of S1's CPI training was up to date. C1’s IPP revealed C1 requires constant supervision during waking hours to prevent injury/harm in all settings. C1 has disruptive behaviors that interferes with social participation almost every day. LPAs review of C1’s Behavior Support Strategies in their Individual Support Plan indicates C1 should be given one step instructions. In Crisis Plan the priority would be for staff to intervene to keep C1 safe and staff should use a most-to-least prompting procedure.

Based on staff interviews and consistent statements, the allegation is Substantiated at this time.

Deficiency cited (refer to LIC9099-D) Exit interview conducted. Appeal rights provided. Copy of report provided.