Complaint Investigation Report

four (4) staffs indicated that they did not inappropriately restrain C1. Four (4) of four (4) staff interviewed revealed that on 01/29/2025, they did not inappropriately restrain C1. Three (3) of three (3) staff interviewed reported that no restrained was conducted on 01/29/2025 when C1 was on video call with C1's physician as they just redirected C1. During the facility visit on 02/03/2025, LPA Brown witnessed C1 agitated, exhibited aggressive behavior to C2 and observed Staff #3 (S3) and Staff #4 (S4) redirected C1 with Staff #1 (S1) assistance. Moreover, LPA Brown noted that S3. S4 and S1 were not rough when they were redirecting C1. C1's Inland Regional Center (IRC) Consumer Services Coordinator (CSC) informed LPA Brown that they are aware of C1's disruptive behaviors, aggression towards others, self-injury, destruction of property, wandering away and emotional outbursts. C1's IRC CSC added that staffs at the facility were aware that they will only conduct CPI if there's a danger to C1 or towards them. Also, per documents review, LPA Brown observed that four (4) of four (4) staffs at the facility have updated emergency intervention (CPI) certification maintained in their facility file.

Second allegation: Client in care sustained unexplained injury. The investigation was conducted by LPA Melody Brown which consisted of file review, observation and interviews with relevant parties. During the investigation, LPA Brown was not able to obtain sufficient evidence to support that client in care sustained unexplained injury. LPA Brown interviewed C2 and C2 stated that C2 was not aware of a client in care that sustained unexplained injury at the facility. C2 reported that there's no incident that C2 observed C1 sustained unexplained injury. LPA Brown unable to interview C1 as C1's unable to answer LPA Brown's questions. Four (4) of four (4) staff interviewed denied that C1 sustained unexplained injury while in care at the facility. Four (4) of four (4) staff interviewed reported that C1 arrived at the facility from the hospital on 11/2024 with bruises on face, arms, hands, legs. Four (4) of four (4) staff interviewed shared that they took a picture of C1's bruises when C1 arrived from the hospital on 11/2024 and they informed C1's Inland Regional Center (IRC) Consumer Services Coordinator (CSC), family member and Community Care Licensing Division (CCLD). C1's IRC CSC indicated that C1 has a habit of throwing self on the ground, self-injury behavior of biting C1's arm, or scratching self. C1's IRC CSC informed LPA Brown that C1 arrived at the facility with bruises and it did not happen at the facility. During the facility visit on 02/03/2025, LPA Brown observed C1 biting C1's arm and C1 throwing self on the ground.