Complaint Investigation Report

LPA interviewed ten (10) staff and seven (7) of ten (10) staff were able to corroborate the allegation. Two (2) clients interviewed were not able to answer questions. The incident occurred on 03/21/2025 at around 12:00 to 12:30PM. According to some staff statements, C1 was in distress and yelling loud. One (1) staff went to the nautical room to assist with C1 after one staff radioed for help. There were 3 staff present. Some staff stated that C1 will yell when C1 wishes to use the bathroom or wants to get up. One staff stated that they were instructed by manager to not let C1 walk around with out shoes for C1 safety. Several staff stated they witness S10 preventing C1 from getting up from chair. S10 stated that C1 was pushing S10 and other staff trying to get up. S10 denied restraining C1. S10 admitted that C1 was pushing S10 and other staff in attempt to get up and was not allowed by S10 and stated S10 was using CPI. LPA interviews revealed that S10 use S10 hands and arm as restraint to prevent C1 from getting up from chair. Seven (7) staff stated they witness S10 using restrain on C1. LPA asked several staff if S10 may have been using CPI and all seven staff stated that it was not CPI, that it was clearly a restraint that is prohibited. There is enough evidence to substantiate this allegation.

Allegation: Staff yelled at client. It is alleged that staff yelled at resident. LPA interviewed 10 staff and one (1) staff of ten (10) staff witness S10 yelling at C1. One staff stated that one (1) staff yelled at resident and said the following: “"STOP IT, SIT DOWN, YOU NEED TO CALM DOWN!” In aggressive and loud tone. There is sufficient evidence to substantiate this allegation.

Based on LPAs, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were discussed and provided.