Complaint Investigation Report

Regarding the Allegation : Staff left clients in the car alone unsupervised.

This complaint alleged that the facility did not provide supervision while residents were inside the facility vehicle. Records review indicate the following: Physician report indicate R1 physical and mental status is “poor”. The incident report indicates that R1 wanted to harm staff and R1 self. ISP plan noted that R1 has mental issues. Module enrollment CS transportation procedure, this document establishes procedures to help promote the safety and well-being of residents and staff during vehicle transportation. Interviews indicate the following: 2 out of 2 staff deny the allegation. R1 is currently at the hospital for 5150 hold and could not be interviewed according to the incident report dated 06/27/2025. R2 indicates that staff never leave residents inside the facility van alone.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff left client in the car alone unsupervised” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Manager Ryan Mcguire (S1).