Complaint Investigation Report

LPA Valerio interviewed 4 staff members (S1 - S4). Staff 1 (S1) stated most of the residents work with a Registered Behavior Technician, have an assigned service coordinator with Alta Regional Center, and have an assigned staff member. All staff interviewed reported they follow the resident's Individual Program Plan to assist the residents. S1 stated resident 1 (R1) needs to be redirected by staff everyday due to his behaviors and actions. S1 stated R1 has caused two new staff members to quit on their first day of work. S1 reported that male staff were put on shift to assist with R1. R1 can have up to 3 staff assigned to him at one time. The other residents have separate staff assigned. Staff 2 (S2) stated there are no residents in the home that would be considered a risk. S2 stated, "there are staff with the residents at all times. We go on daily walks. Interactions with neighbors are just waves." Staff 3 (S3) stated R1 is the resident who elopes mostly. When R1 elopes, staff follow him right away. The facility has an alarm system that will sound if any of the doors or windows are opened. S1 stated alarm systems, doors, and windows have been replaced due to damages caused by R1. S3 reported that five staff members have been hit by R1. S3 has been hit in the back of the head a couple times by R1. Staff 4 (S4) stated, "We really tried everything. It is not really working. I do not know what else we can do." S4 reported that on S4's first day of work R1 hit R1 in the head. S4 stated that R1 knows when it is the staff's first day of work. On a co-worker's first day, R1 ran outside and walked to a busy street behind the home. Staff followed him while directing traffic away from the resident. Another staff member followed in a car in an attempt to get R1 into the car. R1 would not get in the car and was hitting the co-worker in the face. Another incident, reported by S4, involved another resident. R1 became agitated and started to hit another resident in the face. The other resident's face became swollen after the incident.

LPA Valerio reviewed facility documentation. According to Alta Regional Center's Individual Program Plan for R1, "[R1] demonstrates a high level of AWOL and elopement behaviors. [R1] attempts to leave his care home without staff on average 30 times a month…This causes a large safety concern. " According to R1's Function Analysis Assessment and Behavior Intervention Plan, R1 had a total of 780 disruptive behaviors, 116 physical aggression encounters, and 38 elopements over the course of a 3 month period in 2021. The facility has sent notifications of incidents to R1's conservator, Alta Regional Service Coordinator, Elk Grove Police Department, Ombudsman office, and Community Care Licensing office. The facility has worked closely with the conservator and Alta Regional Center to minimize risk and behaviors.