Complaint Investigation Report

Review of C1’s behavioral services annual report dated October 2025 revealed that C1 will bang their head or teeth on the ground. C1 will also bite or scratch their arms. Interviews with staff corroborated C1’s self-injurious behaviors. Review of facility records revealed that staff maintained a log for C1’s self-injurious behaviors and on November 24, 2025, there was a total of eight self-injurious behaviors logged. Interviews with staff and outside sources did not reveal that C1 was restrained in their closet, nor did they reveal that staff hit C1. Review of C1’s Medication Administration Record (MAR) revealed that on November 24, 2025, C1 was administered their medications and interviews with staff corroborated C1 received their medications. Interviews with staff and outside sources did not reveal that staff had not bathed C1 nor did staff not feed C1.

Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not prevent a client from sustaining injuries while in care, staff inappropriately restrained a client in a closet, staff hit a client, staff mishandled a client's medication, staff did not meet client's bathing needs, and staff did not provide client with meals. Based on the foregoing, the allegations are unsubstantiated. This finding means that although the allegations may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted with Administrator Olajumoke Ijabadenuyi, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.