Complaint Investigation Report

LPA reviewed 9 staff files consisting of 1 Clinical Director, 1 Nurse, 1 Therapist, and 6 Behavioral Health Technicians. Review of staff files showed that 9 of 9 staff files had proof of new orientation training completed timely as required by Title 22 regulations.

There is an allegation of “Staff did not allow resident to leave facility.” Information provided by complainant stated that C1 wanted to self-discharge themselves from the facility and the facility wouldn’t allow them to leave. Interview conducted with Chief Operating Officer (COO) revealed that on May 11, 2025, C1 had been yelling, screaming, and was emotionally deregulated. Per COO, they contacted San Rafael Police Department (SRPD) because C1 had been screaming and hitting themselves with a plastic cup causing their forehead to become swollen and form a bruise. Per COO, C1 required one-on-one supervision which couldn’t be provided as C1 wanted to stay outside to smoke and be on their phone and they needed staff to be inside the house to supervise other clients. C1 asked to go for a walk but SRPD told C1 to either stay at the house or go to the hospital. C1 was taken to the hospital where they were placed on a 5150 hold. Review of Facility’s House Rules stated that clients who participate in the program “must remain on the property grounds unless accompanied by a staff member. Leaving the property is prohibited and may result in staff contacting local authorities and/or discharge from the program.”

Based on interviews conducted, record review, and observations made, these allegations are Unsubstantiated .

A finding that a complaint allegation is Unsubstantiated means that 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.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.