Complaint Investigation Report

Regarding the allegation that staff forced clients to go to their rooms, the following was revealed: During the interviews with clients, C1 reported that when clients have behaviors and she feels in danger she goes into her bedroom. C1 stated that once the clients relax, she comes out of her bedroom. During the interviews with staff, S1 reported that when staff put the clients in their bedroom is for their safety. S1 stated that some clients bite or make threats about stabbing staff with a pen. Per S2, when clients have behaviors, the clients are redirected to their bedrooms for safety. S2 reported that the clients come out of their bedroom once the situation settles. During the initial visit and subsequent visit LPA tour the facility and observed the clients hanging out in the living room and/or front of the house.

Regarding the allegation that staff did not allow client use their own television, the following was revealed: During the interviews with clients, C1 reported that she is allowed to use the television at any time. During the interviews with staff, S1 reported that one client likes to fabricate stories and stated that the clients are allowed to watch the television. Per S2, staff always allow the clients to watch television. S2 reported that each client has a television in their bedroom. During the subsequent visit LPA observed that three of four clients have a television in their bedroom. The remaining client prefers to use their laptop.

Regarding the allegation that staff mismanaged client's medications, the following was revealed: During the investigation LPA reviewed documents including the Medication Administration Record (MAR) dated January/February 2025 for clients, C1 through C4. Per MAR, C1 through C4 were given their medications as prescribed. During the interviews with clients, C1 reported that she gets her medications on time and reported that she has never missed her medications. During the interviews with staff, S1 and S2 reported that staff do not mismanage the clients' medications.

Regarding the allegation that Hazards are accessible to clients in care, the following was revealed: During the initial visit and subsequent visit LPA tour the facility and observed that hazard chemicals and toxins were locked and inaccessible to clients in care. The chemicals are located on a locked shed on the side of the house. During the interviews with clients, C1 reported that she has not seen chemicals or hazard materials. During the interviews with staff, S1 reported that hazard chemicals are locked in a shed in the backyard. Per S2, the chemicals are in a shed that is always locked.