Complaint Investigation Report

The investigation revealed the following:

Allegation: Staff physically abuses resident. It is alleged that a staff "karate chops" and kicks a client in the leg. Some staff interviewed stated that they had heard about the incidents from another staff member, even if they had never witnessed them. S3 corroborated the allegation and stated that they had questioned the staff members regarding this alleged incident following LPA's visit on 8/07/2025. S3 stated that S1 admitted to ‘karate chops’ and kicked a client in the leg as a way of protecting themselves when the client displayed an aggressive behavior. S3 also stated that one of the staff admitted to witnessing the alleged incidents that happened months earlier during their shift. S3 stated that they will be providing training on abuse and clients' rights right away, to ensure that this type of incident does not happen again. C3 stated that they had not witnessed the alleged incident, however, they had seen staff restrain and grab a client’s hands, put them on the couch to calm down. LPA attempted to contact the Service Coordinator at San Gabriel Pomona Regional Center, but no response received. Based on the information received and interviews conducted, the allegation is substantiated.

Allegation: Staff do not ensure facility has an adequate food supply. It is alleged that the facility runs out of food every couple of days. Some staff interviewed stated that grocery shopping is done weekly by the Administrator. However, S1 stated that they ran out of food because the new staff did not follow the meal schedule, let the clients choose what they wanted to eat and overfed them. C3 stated that sometimes, they run out of food, and staff will either buy food for the clients or try to make something using what’s left in the refrigerator/freezer. Additionally, C3 stated that C3 buys their groceries at their own expense because the availability and variety of the food provided to them are not satisfactory. During the visit, LPA observed that the facility did not maintain sufficient supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days in the refrigerator, food pantry/snack storage areas. LPA attempted to contact the Service Coordinator at San Gabriel Pomona Regional Center, but no response received. Therefore, the allegation is substantiated.