Complaint Investigation Report

LPA Valerio reviewed five (5) photos. Photo 1 is a picture of an unidentified staff member facing the kitchen cabinets. In the photo, there is R1 sitting in a wheelchair behind the staff member. Photo 2 is a photo of R1's back in the wheelchair showing a cloth around R1's torso and then tied around the back of the wheelchair. There is a pink circle around the knotted clothing item appearing to hold the cloth together. Photo 3 is a picture of R1 sitting in the wheelchair with R1's shirt back over the handlebars and a sweater wrapper around the torso. Photo 3 shows two long sticks that are lodged through R1's wheelchair wheels. Photo 4 is a picture of the side profile of two residents residing in the home. Photo 5 is a close-up picture of R1's wheelchair wheels. The picture shows two sticks placed through the wheels.

LPA Valerio observed the facility on 10/07/2025. Based on LPA's observation of the facility, the kitchen cabinets in the photos match the kitchen at the facility. LPA also compared the residents pictured in the photos with the residents present in the home. Two (2) out of two (2) residents were present during LPA's visit.

LPA Valerio reviewed facility documentation. According to R1's Individual Program Plan and LIC 602 Physician's Report, R1 is able to ambulate without an adaptive device. R1 does not have documentation to support the use of a wheelchair.

According to the facility's program design, the facility is not licensed or vendorized to use restraints of any kind for the residents in care under any circumstances. The facility is vendorized through Alta California Regional Center as a level 4i home.

LPA Valerio interviewed three (3) out of the four (4) residents in care. Residents express feeling safe, enjoy living at the home, and did not indicate any concerns.