Complaint Investigation Report

" Staff do not adequately supervise resident in care."

It was alleged that staff were not supervising Client #1 (C1) during an outing in the community where a member of the community was injured by C1.

LPA attempted to conduct an interview with C1, however C1 was unable to communicate and answer interview questions. LPA conducted (2) staff interviews which revealed that Staff #1 (S1) is a one to one staff for C1. Staff revealed that C1 requires a one to one staff in order to keep C1 safe. Staff including S1 revealed on 03/16/2026, S1 was with C1 at the park. S1 revealed they were standing next to C1 when they ran away and S1 followed C1. S1 revealed that C1 hit a community member and called a second staff to meet them to assist in calming C1 down from the incident. Interviews with staff revealed that they had asked the Regional Center for C1 to have a (2) to (1) assistance for C1 prior to the 03/16/2026 incident.

LPA reviewed C1's Activity Schedule/ Behavior Escalation Guidelines which revealed a behaviorist plan for C1's behavior Crisis Prevention Strategies. On Page 3, Item 5, it states CPI Interim Control Position Two Man Control Position to be used if C1 present a threat to themselves or others.

Based on LPA’s interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is substantiated. California Code of Regulations is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.