Complaint Investigation Report

9099C-2... On April 11, 2025, this staff stated she was off-site and called staff, (S1) and she heard (C1) emotionally apologizing to (S1) and he would take his meds", stating (C1) "only refused to take his meds that night for (S1) but takes them for all other staff". The lead staff stated (S1) and (C1)"typically" get along but when (C1) was told he could not go out, as there was "no "pm" driver that night to pick up him", he became very upset.

A representative from the Regional Center stated (C1) initially stated he got into a physical fight with (S1) on 4/5/25; however, then changed the details of the story and confirmed he did not sustain any injuries or bruises from the physical altercation. A facility nurse confirmed on 4/10/25 that there were no bruises observed to (C1) following the incident.

The Ombudsman stated when (C1) described the incident to him, there were inconsistencies in (C1's) story with each telling. On 4/17/25, when meeting with (C1), (C1) began yelling at the Ombudsman when he told (C1) that while he is independent, due to his behavior, he needs staff supervision as all times. The Ombudsman stated he does not know what happened during the reported incident but from (C1's) telling and how he responded to Ombudsman's interview, it seems clear that (C1) did not respond to staff as calmly as he indicated he did.

The internal investigation notes the Administrator stated she was contacted on 4/5/25 by (S1) to confirm if (C1) could attend a dinner in downtown Sacramento without staff and she stated he could not without staff. Additionally, there were no approved drivers on the shift to drop off or pick up (C1) from the event. Further, the Administrator reported that (C1) was upset after being told he could not attend and began throwing items from his room and at staff and that (C1) was refusing his medications. The Administrator confirmed there were no other communications from staff that night about any additional incidents.

Charting notes entered by NOC staff, (S3) note that when (S3)arrived on 4/5/25 at 10:00 pm, he heard yelling and screaming and (S1) came outside and asked for assistance as (C1) was "having a major behavioral problem". Notes state that (S3) heard (C1) to be "verbally attacking (S1), and they argued for a moment but it escalated to (C1) throwing things at (S1).