Complaint Investigation Report

The investigation revealed the following:

Allegation: "Due to lack of supervision, resident threatens/is aggressive to another resident ." It is alleged that C1 is scared of C2 because C2 has threatened to hit C1 with a belt, has been aggressive toward C1 and bothers C1 frequently. (4) out of (4) staff interviewed stated that C1 and C2 have 1:1 care and 2:1 care when out in the community. All staff interviewed stated that on Sun., 10/05/2025, an incident happened where without provocation, C2 came out of her room with a belt and attempted to hit C1 while C1 was coming out of the room. Staff interviewed stated that no one was hurt since staff responded quickly by preventing C2 from striking C1 and were able to de-escalate the situation. All staff interviewed indicated that staffing is sufficient to provide proper supervision and care to the clients. S1 indicated that additional care plans for the clients, such as more activities and medication evaluations are being reviewed to prevent future client to client conflicts. Staff confirmed they received required training and know how to handle clients' aggression. Interview with C2 stated that C1 was yelling all night which caused C2 not to get sleep and was annoyed by it. C2 indicated that they are satisfied with the care level and supervision they receive. Documents reviewed revealed that (5) staff plus the Administrator/Asst. Administrator are scheduled to work per shift, and (3) staff work during the night shift. Reviewed documents also show that staff received the required training. Service Coordinator at the Regional Center confirmed that there is no ongoing investigation about this allegation. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with clients and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the 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 conducted and a copy of this report was provided to Hannah Orteg a, Interim Administrator.