Complaint Investigation Report

Placement documents and the service plan indicated that C1 was independent, permitted to leave the facility unsupervised, and designated as their own responsible party.

On November 20, 2023, the facility issued C1 a 30-day termination notice and Notice to Quit due to repeated violations of house rules outlined in the admission agreement. The termination was effective December 20, 2023. A review of the termination notice found no violations of Title 22 regulations. Records, incident reports, and interviews demonstrated that C1 repeatedly failed to follow house rules related to pet care, late-night noise, and required check-in/out procedures. Despite being issued a 30-day notice, C1 did not comply with the directive to vacate the facility. In addition, records confirmed that C1 did not pay for room and board for the months of November and December 2023, or January 2024.

For example, on January 19, 2024, C1 left the facility at 6:00 a.m. and did not return by 8:30 p.m. When staff could not locate C1, a missing person’s report was filed with law enforcement in accordance with AWOL procedures. A review of staff actions confirmed compliance with Title 22 regulations. Later that evening, staff learned that C1 had admitted themselves into a higher-level care facility due to a personal crisis. Records confirmed that C1 remained there from January 19 through February 5, 2024, and was later discharged into the community. C1 did not return to the facility or retrieve personal belongings and was unavailable for interview.

Interviews with staff, clients, and outside sources yielded no evidence that staff intimidated C1 or any other client. Staff denied the allegations, and clients consistently described staff as respectful and attentive to their needs. Clients also confirmed that they had never been denied access to the facility, noting that staff were present and available when clients returned from day programs.

During facility visits conducted on February 2, 2024, and December 16, 2024, LPA observed positive staff-client interactions. Clients appeared comfortable, engaged, and appropriately supervised, with no signs of abuse, distress, or intimidation.