Complaint Investigation Report

LPA reviewed a facility annual review dated January 30, 2025, stating that C1 gets along with peers and staff at the facility and has not displayed any behavioral outbursts with peers or staff. C1s IPP and facility annual review do not mention a history of sexual assault or behaviors.

During interviews with C1 it was revealed that C1 walked into the bedroom that C2 and C3 were in and exposed their penis to C2 and C3. C1 informed LPA that C2 told them to stop and they pulled up their pants and walked away. C1 informed LPA that they did not say anything or touch C2 or C3. C1 informed LPA that they realized it was wrong and will not do it again. C1 informed LPA that facility staff spoke with them regarding this incident.

LPA reviewed a physicians report for C2 dated April 8, 2023, stating that they are able to follow directions and communicate their needs, but do not need constant medical supervision. LPA reviewed an IPP addendum for C2 dated September 10, 2024, stating that C2 has had disruptive behaviors such as making false statements. LPA reviewed an IPP for C2 dated December 12, 2024, stating that C2 was issued a formal written notice by the facility due to their behaviors. LPA observed the formal client warning letter dated September 10, 2024, stating that C2 has a history of making false and exaggerated statements.

During interviews with C2 it was revealed to LPA that C1 exposed their penis in front of C2 and C3 and that C1 touched C2. LPA interviewed C2 a second time and it was revealed that C1 did not actually touch C2 at the time of the incident. C2 informed LPA that they spoke with facility staff about the incident that occurred.

LPA was unable to interview C3 due to being at work when LPA visited the facility and not answering their phone when LPA tried to contact them.

During interviews with staff it was revealed to LPA by two of two staff that C2 has a history of false statements and exaggerating incidents that occur. Two of two staff informed LPA that they were initially informed about the incident and was told that C1 touched C2 after exposing themselves and then later informed that C1 did not touch C2 by C1. Two of two staff informed LPA that C1 does not have a history of exposing themselves or a history of sexual assault or sexual behaviors. Two of two staff informed LPA that clients are now to gather in communal spaces instead of their private bedrooms for better supervision.