Complaint Investigation Report

During interviews with the clients, fourteen (14) out of sixteen (16) did not corroborate the allegation. One of the clients interviewed stated that they have never witnessed another client hang up the phone on another client in the facility. Another client interviewed stated that they do not use the facility phone and have never witnessed any altercations surrounding the phone. During interviews with the staff, none of them corroborated the allegation. One staff interviewed stated that no one physically hung up the phone on C1, it is possible that the individual C1 was on the phone with hung up the phone which caused C1 to get upset. Another staff interviewed stated that they had no knowledge of another client hanging up C1's phone call on 7/25/2025. During review of the surveillance camera footage of 7/25/2025, LPA observed that while C1 was using the phone no one intervene on that phone call.

In regards to the allegation that " Staff did not prevent a resident from threatening another resident in care," it is alleged that an unknown tall client had threatened C1 on 7/25/2025, and that staff were not doing anything to address it. During interviews with the clients, thirteen (13) out of sixteen (16) did not corroborate the allegation. One of the clients stated that they have never witnessed clients threatening one another in the facility. Another client interviewed stated that while they have witnessed clients threaten one another, staff do a good job in intervening in all these incidents to prevent further escalations. During interviews with the staff, none of them corroborated the allegation. One of the staff stated that no one has been threatening C1 recently, and that they may be recalling an incident that occurred months ago, in which staff intervened when C1 and another client had a verbal altercation. Another staff stated that they were not aware of C1 being threatened by any clients recently. During review of the surveillance camera footage of 7/25/2025, LPA did not observe any clients threatening C1.