Complaint Investigation Report

During the course of the interviews with staff, Staff 1 (S1) reported that staff did not walk in when the client was naked. S1 stated that C1 has fabricated similar allegations with other staff. Per S2, staff did not walk into the client's bedroom when client was naked. S3 reported that staff did not walk into client's bedroom when the client was naked. Per S4, he never walked in when C1 was changing.

Regarding the allegation that staff physically assaulted client, the following was revealed: During the course of the interviews with individuals four of seven individuals denied the allegation. During the course of the investigation LPA reviewed documents including the Unusual Incident/Injury Report (UIIR) dated January 2, 2024, for C1. Per UIIR, on January 1, 2024, C1 dial 911 making allegations against staff. Per UIIR, after the call with the 911 operator, C1 was trying to fall to the floor and bang her head on the floor. Per UIIR, C1 became aggressive towards staff, swung at staff with a close fist and attempted to bite staff. During the course of the interviews with staff, S1 reported that staff have not physically assaulted the client. Per S2, staff did not physically assaulted the clients. S3 stated that staff did not physically assaulted C1. Per S4, he has never hit, scratch or kick C1.

Regarding the allegation that staff did not allow client to call authorities, the following was revealed: During the course of the investigation LPA reviewed documents including the UIIR dated January 2, 2024, for C1. Per UIIR, on January 1, 2024, C1 dialed 911 making allegations against staff. LPA reviewed documents including the Nantucket Home Antecedent Behavior Consequence Data dated January 3, 2024, for C1. Per Antecedent Behavior Consequence Data, during the Police visit C1 wanted to speak to the Police officers alone and states that when Police were done talking to C1 that C1 was assisted by staff into the kitchen. During the course of the interviews with staff, S1-S4 reported that staff would not tell C1 not to use the telephone and/or stated that C1 was never denied access to the telephone.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegations occurred as reported due to conflicting information. Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred; therefore, these allegations are deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with facility representative, and a copy of this report was provided to the facility.