Complaint Investigation Report

Regarding the allegation: Staff left client unsupervised while in care. It is alleged that staff #2 and #3 (S2 and S3) left C1 unattended while shopping at a department store. Three (3) of three (3) staff interviewed stated during the trip to department store on 11/17/25, C1 is on a 2:1 ratio while out in the community. According to records reviewed, C1’s behaviors include fabricating stories, mood swings, and demanding attention, physical aggression, and verbal aggression. Staff stated C1 required 1:1 ratio in the facility and 2:1 when out in the community, residents are given space to express their behaviors. S2 and S3 took C1 to the store, after C1’s shopping was completed C1 wanted to leave and started displaying behaviors. C1 wanted space from staff, S2 and S3 gave C1 the space and watched from a safe viewing distance in the store. After the shopping was complete C1, S2 and S3 returned to the facility without incident. Based on interviews conducted and records reviewed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: Staff emotionally abuse client in care. It is alleged that staff were emotionally abusive towards the client in care by following them in the community. Three (3) of three (3) staff interviewed deny this allegation, according to staff interviewed they stated they are aware of C1’s behaviors and encourage only health habits and behaviors so C1 can be productive in and out of the community. Interviewed staff stated they communicated with C1 in positive voice and tone, encourage and validate C1’s feelings to express themselves calmly. Due to C1’s behaviors, two staff follow C1 when C1 walks out of the facility to keep C1 from injuring themselves. Interviewed staff indicated that C-1 has a history of fabricating stories which are monitored and recorded by staff. Interviewed staff indicated that they have not witnessed any staff emotionally abusing clients. Client interviews revealed that staff are not emotionally abusive towards them. Clients indicated that they have not witnessed any staff abusing clients. Client interviews revealed that staff are nice and respectful and did not have any concerns regarding this matter. Interviews and reviewed documentation do not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted, and a copy of this report was provided to Administrator Ronnie Chua.