Complaint Investigation Report

During today’s visit, LPA and Staff Roxana conducted a tour of the physical plant areas at 11:04AM to ensure client health and safety and the facility is in compliance with Title 22 regulations. In addition, LPA Huynh conducted interviews with client and staff. Based on interviews, documentation gathered and reviewed, as well as photos and videos provided, the following was determined:

Allegation: “Staff did not provide adequate supervision to client in care.”

On 10/29/2024, it was alleged that Client #1 (C1) was left alone outside the facility while having an emotional breakdown. Interviews with the Licensee, Staff #1 (S1), and C1 revealed that C1 arrived at the facility in their personal car and parked on the facility’s driveway. C1 then informed the Licensee of their arrival via text message where S1 then greeted C1 on the driveway, S1 calmed C1 down, and brought C1 inside the facility where they began the intake process. Ring doorbell footage provided by the Licensee shows S1 greeting C1 at 4:14PM and both entering the facility at 4:15PM. Admission Agreement for C1 was signed at 4:19PM and at that time, C1 became a client of the facility. Interview with one (1) direct Witness (W1) revealed that C1 was leaning against their car “sobbing” but was not causing a disturbance. W1 was concerned about C1’s emotional state. W1 observed C1 on the driveway for ten minutes, during which S1 came outside and spoke with C1, and both entered the facility. W1 provided the Department an eight second video of C1 leaning on the rear of C1’s car crying.

On 04/25/2025, the Department received additional information for an incident that occurred on 04/18/2025. On 04/18/2025, Client #2 (C2) was allegedly wandering the neighborhood streets in distress and abandoned their belongings on the sidewalk. LPA interviewed three (3) Witnesses (Witness #2 - W2, Witness #3 - W3, and Witness #4 - W4) regarding the incident. W2 observed C2 walking past their home at 3:05PM with two suitcases and provided a photo. W3 stated they observed C2 sitting at a nearby bus stop at 4:00PM and was not being disruptive. W4 stated they did not see C2, but at 4:00PM they arrived home and observed an abandoned suitcase on the sidewalk in front of their home. W4 revealed that law enforcement was called at 4:15PM and arrived at 4:55PM where they retrieved the unattended suitcase. Ring doorbell footage and interviews revealed that C2 initially arrived at the facility’s location between 1:00PM and 2:00PM, however C2 gathered their belongings and left the property at 3:03PM. As C2 had not yet been admitted, C2 was not a client at that time. At 5:20PM, C2 returned to the facility, was greeted by S1, and successfully completed the facility’s intake process. C2’s Admission Agreement was signed at 5:30PM and at that time, C2 became a client of the facility.