Complaint Investigation Report

Allegation: Staff did not prevent residents from engaging in a physical altercation. The complaint alleges that on October 15, 2025, during breakfast meal time in the dining room resident (R2) got upset and threw a chair, threatened their life, and swung a cane at resident (R1). According to information obtained, R1 tried blocking the chair with their hand, but got hit in the torso area of the body. A total of 5 staff were interviewed. The majority of the 14 residents interviewed did not remember the incident. However, they stated that most of the time staff respond immediately to resident altercations. Pertaining to this specific incident, residents stated that staff immediately intervened and prevented injury. Staff interviews revealed that staff immediately intervene and tried to stop residents (R2 & R3) from attacking R1. Staff said that R2 & R3 falsely stated R1 spit on R3's food and tried to manhandle R3. Based on video surveillance footage review, the findings indicate that all three residents were eating breakfast in the dining room when R3 had an outburst and threw their plate at R1. Resident (R1) reacted but was not aggressive nor touched R2 & R3. Video footage confirms R2 threw a chair at R1. It also shows that there was staff supervision in the dining area, and staff immediately responded to the altercation. Based on record review, residents (R2 & R3) have history of hallucinations and impaired impulse control. The facility serves mentally disabled individuals, of which many have aggressive behaviors that are unforeseen. Facility staff handled the situation per facility procedures by separating the residents, restraining resident (R2), and reporting to the CCL Regional Office. Local law enforcement responded to the incident.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation are Unsubstantiated .

An exit interview was conducted and a copy of the report was discussed and provided to Joyce Garcia.