Complaint Investigation Report

Interviews conducted with two out of four staff stated that C1 had ran out of the facility with a stick and approached a group of people on a walk. Staff (S1) stated C1 talked to the group of people and after a while they were able to redirect C1 back into the facility. Community Care Licensing (CCL) received an special incident report (SIR) on 3/25/2026 stating on 3/23/2026 C1 began chasing staff attempting to hit them when C1 ran into the neighborhood with two staff following closely and C1 picked up a stick and ran towards a group of neighbors and staff were able to redirect C1 back into the house.

Complainant states staff does not provide adequate supervision resulting in resident engaging in inappropriate behavior. Complainant stated they have observed client (C2) pull down their pants and urinate in front of the house and observed C2 to pull down their pants. Complainant stated two staff were present during the urination incident and other individuals are aware of C2 pulling down their pants and urinating. LPA attempted to reach out to another individual who had allegedly witnessed C2 pull down their pants and urinate and LPA received no response. Interviews with two of four staff members revealed that C2 did have a behavior when C2 urinated outside of the facility and staff used a towel to cover C2 from individuals passing by. Staff (S2) stated they will carry around a towel to cover up C2 in the event C2 urinates outside of the facility. Interview with staff (S3) stated that they will ask C2 if they need to use the bathroom before they leave the facility to prevent C2 from urinating outside of the facility. Per C2s Golden Gate Regional Center Individual Program Plan (IPP) dated 08/15/2024 under A. Health and Well-Being, it is listed that C2 has inappropriate urination. Review of C2’s IBST dated 03/17/2026, C2 requires 2:1 staffing ratio during waking hours. For community outings staffing ratio is 2:1 with one staff arm’s length, second staff within line of sight able to response promptly. C2’s IBST’s Monthly review dated 03/17/2026; under Inappropriate Urination Per Month, shows since a new roommate moved into the facility on 8/2025 C2 has had 10 community urinations, with three being in August 2025, one in October 2025, three in November 2025, and three in January 2026. Under Target behavior #4: Inappropriate Urination, the current objective is for C2 to engage in less than 2 episodes per week of inappropriate urination for 3 consecutive months by the time of their Annual August 2026 IBSP. The Operational Definition for Inappropriate Urination is stated as, Type A) Anytime that C2 pulls down their pants or is nude and urinates anywhere outside of the bathroom and Type B) Anytime C2 urinates in the bathroom but misses or does not attempt to go in the toilet. Under Individual Behavior Support Strategies on page 29 under Inappropriate Urination, states there should be at least 2 staff that are in close proximity (1 near the front door with an Ukeru pad close), Verbally ask C2 if they want the big or little bathroom while pointing in that direction, staff should place themselves between C2 and others, outdoors, or communal spaces, use a pad or other item (sheet, towel) to block view from any community members or other residents, if C2 attempts to go out the front door staff may stand near the door, prompting C2 to the restroom however, staff may not block C2’s movement or access to the door.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.