Complaint Investigation Report

It is alleged there was bruising on Client #1’s (C!) arms which was caused by staff restraining C1 during a behavioral episode on May 28, 2026..

Based on investigation, on May 28, 2026, at 6:50 AM, C1 was upset that the staff was serving cereal to them because they were told by their doctor it was too sugary. S1 and S3 stated to C1 that they were allowed to have cereal. C1 was upset and S1 and S3 started to de-escalate the situation. Based on interviews, S1 and S3 believed C1 was heading to their room after they de-escalated situation. C1 did not go to their room and opened a kitchen drawer and took a spatula then headed toward another client’s room to attack them. S1 attempted to redirect C1, but C1 was being aggressive towards S1 in order to attack another client. S1 restrained C1. When C1 calmed down, C1 headed to their room and called 911. It was stated on the facility incident record, C1 call 911 and wanted to be taken to the hospital.

Police came and the officer reviewed the situation and determined that C1 did not need to be hospitalized. Based on facility incident record, after the police left the facility, C1 proceeded to be aggressive verbally and physically towards all staff and all clients. Then C1 went to the kitchen and acquired another kitchen item to attack staff and clients. S1 proceeded to restrain C1. Based on interviews with S1, S3, S4, and C2, they all stated the S1 restrained C1 in a proper and gentle manner. S1, S4, and C2 stated that C1 apologized to all staff and clients for their behavior. Based on interviews, S1, S3, and S4 stated that S1 restrained C1 according to their training on restraining and CPI holds. S1, S3, and S4 stated body check assessment for C1 had not injuries of bruises, scratches, or other concerns. Based on training records S1, S3, and S4 have CPI training that are current and valid.

On May 29, 2026, S1 and S5 accompanied C1 and C2 to an outing. They arrived at the store to purchase some personal items. C1 stated they wanted to buy shoes and other item and they admitted they were aggressive on the ride back to the facility. They stated they were sorry and were remorseful for attacking S1 and C2 during the ride back. S1, S5, and C2 stated there was incident where C1 pulled C2’s hair and C2 responded by punching C1 in the face. Later on during the ride, C1 attacked S1 while S1 was driving. S1 pulled the car to the side and informed the Administrator of the situation. S5 escorted C2 out of the car, while S1 discussed with C1 their actions. S1 stated they restrained C1’s arm and knee until she calmed down according to CPI training. C1 agreed to move to the back of the van. S5 and C2 returned to the car.