Complaint Investigation Report

Allegation: Staff are retaining a resident who requires a higher level of care

The detail of the complaint alleges that “C1 hits himself a lot on his head and body to the point of leaving marks and is red and bangs on doors all day. We cannot help him here.”

On 8/21/25, LPA interviewed A1 who denied allegation stating C1 is supported by 2:1 staffing ratio, and when he is out in the community a 3:1 ratio. A1 went on to state that staff are also supported by placement agency’s Behavior Specialists in addition to a facility Behavior Specialist who come to give staff techniques on how to deal with client behaviors.

On 8/21/25, LPA interviewed 6 staff (S1-S6) regarding the above allegation and of those interviewed, 5 out of 6 denied the allegation, stating that they can handle C1’s behaviors. 1 out of 6 stated that some staff can’t handle C1’s behaviors because they haven’t had experience with “extreme behaviors that C1 exhibits.”

On 8/21/25, LPA obtained, reviewed, and evaluated a copy of C1’s Individual Behavior Support plan for May and June 2025 which indicates that the Behavior Specialists are working with C1 on a consistent basis.

On 8/21/25, LPA spoke with Behavior Specialist (W1) from the Department of Developmental Services (DDS) via telephone who stated that C1 is in the highest level of care in a community care setting and that C1 has behavior challenges, but it is C1’s first placement and C1 is adjusting. W1 expressed that she can reach out to the Placement Agency to discuss the need for additional support to assist the staff.