Complaint Investigation Report

Allegation: Staff did not keep client free from corporal or unusual punishment, humiliation, intimidation, and threats. Regarding the allegation it was reported that staff got into a verbal and physical altercation with Resident #1 (R1). LPA’s interviews with R1 and the administrator corroborate that an incident occurred between them on 05/12/2025 over R1’s attempt to grab food out of the freezer and recording the encounter that escalated from verbal to physical. Each party identified the other as the instigator.

On 05-16-2025 LPA Rios received and reviewed video of 05-12-2025 incident. The video obtained shows two individuals, one is seen in the kitchen and the other is behind the recording device. They are heard discussing dinner. The video captures an individual identified as R1 whose tone, while not overtly upset, appears combative and boundary-testing. R1 is heard posing a hypothetical scenario, then acting on it by approaching the freezer and stating, “So if I were to go right here, and grab these. What exactly would you do? How is this going to go down?” As R1 reaches into the freezer, the administrator, initially facing the sink, turns and moves toward R1, reaching into the freezer while saying, “Excuse me, (R1’s name).” R1 responds, “You’re getting in my personal space.”

The video shows that while the administrator maintains a firm tone and does not raise their voice, they dismiss R1’s concerns and physically approach R1 after R1 reaches into the freezer. Although R1 moves closer to the administrator by reaching into the freezer the administrator moves around the refrigerator doors, standing directly next to R1. This caused R1 to loose grip and drop the phone. This action does not prioritize safety. According to R1's Individual Support Plan, it states, staff should stay out of R1s' reach and position themselves on the other side of a piece of furniture or another barrier and only move closer to keep R1 and other peers in the environment safe. The administrator’s response cannot be justified as a reaction to unexpected behavior, as R1 has a documented history, and Behavioral Support Strategies that should have informed their approach.

LPA’s review of R1’s IPP meeting date 11/12/2024 revealed not verbatim, R1 is clear when they are upset. R1 has been resistive at times when they feel they are not being respected. R1 has been doing well with self-regulating. Often needing time to themselves to process. IPP also revealed R1 has moved several times in 3 years usually due to breaking house rules regarding marijuana and increased agitation. Interview with R2, S1 and S2 revealed they were not present during the incident in question. S1 and S2 revealed they have not encountered issues as the incident described with R1.