Complaint Investigation Report

PD further stated that staff have recently observed a decline in C1's cognitive functioning and have documented those observations. When asked about the facility's grievance procedures and participants' ability to report concerns, PD explained that the program conducts Safe Advocacy Classes , during which participants are educated on how to report concerns to Adult Protective Services (APS), Community Care Licensing (CCLD), law enforcement, and the Ombudsman . PD stated that although C1 has significant visual impairment and is unable to read the posted grievance information, C1 remains cognitively aware and is able to verbally express concerns.

LPA contacted the Reporting Party (RP) by telephone to discuss the allegation. RP stated that C1 initially reported the allegation to care home staff; however, RP did not believe the allegation was accurate. RP stated that C1's poor vision and behavioral responses may contribute to misperceptions. RP explained that even when staff assist C1 with routine care, such as showering, making the bed, or providing physical assistance, C1 sometimes responds by saying, "Don't touch me," "Don't push me," or "Don't hit me," despite staff using appropriate physical assistance. RP stated that these responses appear to be reactions rather than indications of actual abuse.

RP further stated that C1 had previously been evaluated by psychiatric services due to verbally aggressive behaviors, which resulted in adjustments to C1's medications.

LPA also asked whether C1 had ever been threatened with eviction from the care home. RP stated that C1 has previously expressed concerns about being "put out," but staff consistently reassured C1 that no one intended to remove them from the home. RP stated that C1 has resided in multiple care homes in the past and believes C1 may have witnessed other residents being discharged due to behavioral issues. RP believes those past experiences may have contributed to C1's fear of being removed from the facility.

LPA reviewed C1's records, including incident reports from March through June 2026 , the Admission Agreement, LIC 602A , the Individual Health Care Plan, and the Individual Service Plan.