Complaint Investigation Report

The investigation revealed the following:

Allegation: Resident sustained injury due to staff neglect.

The allegation alleges that while C2 was agitated they walked into the room and pushed a chair over with C1 in it, resulting in C1 being injured.

During the tour LPA observed clients were in small groups with a staff. All groups consisted of three (3) clients and a staff, keeping their ratio 3 to 1. Additionally, LPA observed two (2) floater staff available to assist clients to the restroom or to provide monitoring if a client needs to step away from group activities. During an interview with Administrator (S1), stated they are a hands-free facility. They do not hold the client’s hand to guide them and they do not restrain clients in any way when they are experiencing a maladaptive behavior. During interviews with staff (S1-S3), three out of three stated that C2 was exhibiting maladaptive behaviors when they arrived through till they left for the day. Additionally, Staff (S1-S3) stated that when C2 ran from staff into the activity room, S2 ran in after C2 and redirected them to where their their father was waiting for an early pick-up. Interviews with Clients (C1 and C5) two out of two stated they feel safe when they attend program. LPA reviewed C2’s Individual Program Plan (IPP), Behavior Plan and SIR’s and observed that staff followed the behavior plan for C2.

Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Sina Akai, and a copy of this report was provided.