Complaint Investigation Report

It was claimed that lapse in supervision occurred because direct care Staff #1 (S1), who was the only staff present at the time, was sleeping on the job because S1 took too long to respond to and open the front door during two dates in early February 2025. However, investigation showed that the Complainant did not witness S1 sleeping. In their own interview, S1 denied sleeping on the job, and said they responded to the front door timely. Interviews of all four (4) clients who lived at the facility, plus multiple coworkers of S1, aligned to show: None of these persons ever seen or heard about S1 sleeping on the job. On the contrary, clients overwhelmingly said that S1 was immediately aware of their movements and responsive to their needs whenever they came out of their bedrooms. Interview of San Diego Regional Center (SDRC) personnel showed they had no suspicion concern that facility staff were sleeping on the job (or took too long to answer the phone or front door), instead saying staff were “very responsive.”

Client and staff interviews generally aligned to show: On or around 02/11/2025, Licensees purchased a pizza for clients to share. C1 stood near the pizza and double-dipped their food into a sauce that was to be supposed to be shared by multiple clients. C2 made a comment on this and chastised C1 to save some food for other clients to eat. Client #3 (C3), meanwhile, encouraged C1 to sit down so that C1 could eat comfortably. Shortly after, C1 left and walked upstairs to their bedroom. C1 told CCLD that C2 did not say anything further to them, and they simply went their separate ways. C3 told CCLD that C2 did call C1 some names as C1 ascended the stairs, but also that the staff who was on duty quickly intervened to put a stop to that behavior.

Interviews showed that on other dates: C1 and C2 each sometimes engaged in disrespectful name calling towards each other (i.e., it went both ways). C3 sometimes called C2 names, but did not do this to C1. However, whenever staff heard name calling, they quickly redirected/corrected the clients. All clients in care said despite occasional interpersonal spats, the four of them remained socially compatible overall. Each client strongly denied feeling bullied or harassed by any peer, denied feeling uncomfortable living with any peer, and denied wanting to live elsewhere. SDRC performed is own independent investigation of this allegation, interviewing the Compliant, client, and staff, finding there was no evidence of bullying or an untenable situation.