Complaint Investigation Report

Regarding: Staff did not prevent an altercation between residents resulting in resident’s injury.

It is alleged, facility staff did not adequately protect client from being hit by a peer during altercation after client had expressed fear due to being threatened and called racial slurs by peer. It is also alleged, client had asked staff to intervene but instead of addressing the issue, staff advised client to “ignore.”

The investigation revealed the following:

Interviews with four out of four staff (S1-S4) revealed, client came to them initially with concerns regarding peer calling C1 racial slurs. S1-S4 stated, they advised C1 to ignore peer when peer was exhibiting that type of behavior towards C1. Further interviews with S1-S4 revealed, they had heard peer using racial slurs like the N-word and other bad names toward C1, however, they addressed the incidents by continuing to advise C1 to ignore peer and stay away from them. Regarding the physical altercation which took place on 2/15/2025, S1-S4 stated, peer grabbed C1 by their shirt and proceeded to physically attack C1 after staff heard peer calling C1 bad names.

Interviews with clients revealed peer had been using racial slurs like the N-word days before the physical altercation ensued. Interviews also revealed, staff were made aware before the altercation that peer’s behavior toward client was concerning and scared and made them feel unsafe. However, staff advised client to ignore and stay away from peer during the incidents.

Record review indicated, staff did not intervene appropriately by implementing peer’s Individual Program Planning and Behavior Treatment Plan regarding reducing physical aggression, using proper ways to communicate and maintaining boundaries, before the physical altercation ensued.

Based on statements gathered from staff and clients 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) cited on the attached 9099-D.

Exit interview conducted with Olivia Tomines, Administrator. Copy of the report and Appeal Rights provided at the time of visit.