Complaint Investigation Report

LPA Moleski interviewed R1, R2, and R3. In an interview, R1 said that staff tried to break up the argument, and that they got in between R1 and R2 to protect R1. R2 and R3 described adequate staffing levels at the facility. R3 said staff told R3 to stay in their room during the altercation.

LPA Moleski interviewed seven staff members (S1-S7). S6-S8 all described attempts to deescalate the altercation described in the incident report. S6-S8 said S6 attempted to redirect R2 to take a car ride. S6-S8 said R2 went outside, but then ran back inside to attack R1. S6-S8 said S7 and S8 remained inside with R1 and got in between R1 and R2 during the attack. During an interview, Carpio said that, when R2 becomes aggressive, staff are instructed to tell other residents to stay in their rooms, to get in between R2 and any other resident involved, and to try to remove R2 from the situation in order to protect other residents.

During interviews with S1-S7, S3, S4, and S8 voiced concerns regarding staffing levels at the facility.

LPA Moleski interviewed an ACRC service coordinator. The service coordinator said facility staff do “the best they can” supervising and redirecting R2. The service coordinator did not voice concerns regarding supervision at the facility.

In an interview, B1 described aggression reduction techniques recommended to facility staff, including verbal redirection and separating residents from R2 when agitated. B1 did not voice concerns regarding the facility’s ability to provide supervision over R2 or to implement these techniques. In an interview, B2 described behavior prevention techniques, including providing reinforcement for good behavior and removing demands when aggression emerges. B2 did not voice concerns regarding this facility’s ability to provide supervision over R2, but recommended two-to-one supervision for R2. LPA Moleski reviewed a statement written by Carpio received by CCLD on 9/13/23 which states, in part, that facility staff have been instructed to provide two-to-one supervision for R2.

During the course of this investigation, LPA Moleski visited this facility four times, not including this visit. On each of these occasions, LPA Moleski observed adequate levels of staffing and supervision.