Complaint Investigation Report

Allegation: Staff did not provide adequate supervision to client in care.

It is alleged that staff failed to maintain line of sight supervision of C1 during a community outing, resulting in C1 leaving the area unsupervised after becoming anxious when staff was no longer visible. During staff interviews, staff admitted leaving C1 unattended while using a nearby restroom and did not notify C1 or arrange alternate supervision. Staff reported being away for approximately five (5) minutes and returned to find C1 missing. Additional staff confirmed C1 requires one to one supervision and staff are expected to maintain close supervision during outings. During C1’s interview, C1 reported staff did not inform C1 before leaving to use the restroom. C1 reported feeling scared and anxious after being unable to locate staff and believed staff had left the area. C1 reported leaving the park with their significant other and going to the significant other’s nearby home before contacting the facility to be picked up. C1 was not harmed during the incident. During record review, LPA reviewed C1’s Safety Net Plan signed by the facility, C1, and the Qualified Behavioral Management Professional (QBMP), C1’s and the Special Incident Report (SIR) regarding the incident dated 04/02/2026. The Safety Net Plan stated staff are required to maintain continuous line of sight supervision of C1 at all times and remain within approximately eight (8) feet of C1 unless otherwise clinically adjusted by the behavior consultant. The plan also included established community safety procedures.

Based on LPA's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.