Complaint Investigation Report
held onto R1's arm and back directing them away from S2. R1 then turned towards S1 and it's unclear if S1 was pulling R1 or R1 was grabbing S1 as R1's back was turned towards the individual that was recording the video. It is unknown who recorded the video. Interviews with staff (S3, S4, S5, S6, and S7) indicated that they did not witness the incident. The visual and audio of the video showed S1 and S2 laughing during the incident as well as the video recorder laughing.
Interviews with Administrator and Regional Director indicated that the appropriate training was not utilized by S1. Regional Director has conducted the Ukeru pad training for staff and indicated that S2 implemented the correct training of the Ukeru pad. However, S1 did not implement the appropriate training for the situation. Regional Director indicated that staff are not trained to grab a residents' arm the way S1 did in the situation. Interviews with Regional Director and Administrator Assistant indicated that staff are trained to put their hand in a "C" shape to prevent grabbing a resident, which could cause injuries to both resident and staff.
S1 and S2 received training regarding their behavioral intervention plan for R1. S1 received the training on August 22, 2024 and S2 on October 9, 2024. S1 and S2 had also completed their annual Ukeru pad training.
Upon opening of the complaint investigation, S1 and S2 were both temporarily suspended, while the facility conducted an internal investigation. The internal investigation findings have been completed, however, the report is not yet finished. S1 and S2 have since been terminated.
Based on observation of videos, interviews conducted, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.
Exit interview conducted. A copy of the report and appeal rights provided.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction