Complaint Investigation Report

LPA Valerio reviewed facility records dated September 2025 - Present. LPA Valerio reviewed a shared information report dated September 12, 2025 that revealed a similar event. Based on the shared information report, R1 sustained a minor laceration to R1's upper forehead. S1 and Staff 2 (S2) were the Direct Support Staff on shift. S1 was in the staff office when R1 began to banging on the door repeatedly. S2 attempted to redirect R1 with activities but was unsuccessful. S2 noticed blood on the upper portion of the door and on R1's forehead implying that R1 was banging R1's head on the door. Basic first aid was applied, and bleeding stopped. Laceration was approximately 3/4 of an inch and crescent shaped. Wound was not gaping or actively bleeding. R1 did not present in any pain. Staff continued to monitor throughout the shift.

According to interviews, it was learned that S1, S2, and Staff 3 (S3) were present during the incident. According to an interview with S1, S1 denied allegations of physical abuse. S1 stated S1 was in the office writing notes and when S1 went back into the house R1 was bleeding. S1 did not hear any verbal or physical abuse. An interview with S3 revealed similar information; S3 denied any physical or verbal abuse. LPA attempted to interview S2; however, S2 no longer works with the facility and did not return LPA's call.

According to the RP, the RP stated they heard staff yelling "get the f*ck out of my way". According to S1 and S3, they did not hear and did not say that phrase. According to S3, staff have never been observed talking like that to the residents. According to S1, S1 states S1 may talk firm to ensure boundaries and following their care plan; however, S1 treats the residents as if they are family.

LPA Valerio attempted to interview two residents (R1-R2). Due to communication barriers, interviews were unsuccessful. LPA Valerio observed R1 on 12/04/25 and 12/05/25. R1 did not appear to be in any form of discomfort or stress.

LPA Valerio reviewed facility training records. LPA Valerio observed facility staff to have training in mandated reporting and resident behavior care plan interventions.

Based on all the information collected by the Department, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies cited. An exit interview was held with Administrator Hanif, and a copy of report was left at the facility.