Complaint Investigation Report

LPA Colvin additionally observed that in a review of a sample of R1's Consumer Notes for the month of February 2024, R1 had 15 documented behavioral episodes. Out of these 15 episodes, 911 emergency services were only called out to the facility by staff 3 times, and the Riverside County Mental Health Mobile Crisis Line was called 3 times. LPA Colvin questioned staff about under what circumstances they contact 911 for R1's behaviors, and in these interviews, staff relayed that 911 is only contacted if their efforts to redirect R1 are unsuccessful, and R1's self-injurious behaviors are extreme enough that they are worried about R1's physical well-being. An example of this was provided by multiple staff members wherein R1 was bleeding from their head after banging their head repeatedly.

Since interviews and other facility records support the assertion that staff are following the provided Behavioral Support Plan for R1 and other persons interviewed by LPA Colvin who are responsible for oversight of R1's care additionally confirmed that facility staff are following correct procedure, the allegation "Staff are not providing appropriate care and supervision to the residents resulting in facility having to unnecessarily call 911." is UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Administrator Stephanie Olivas and a copy of this report was provided.