Complaint Investigation Report

According to their latest LIC602 Physician’s Report, C1 was diagnosed with Intellectual Disability. San Diego Regional Center (SDRC) records and behavioral consultant records both showed that C1 had a history of self-harm behavior.

The totality of records, interviews, and photographic evidence showed: On 07/23/2025, C1 departed R.E. Care Homes LLC and arrived at their day program site with a pumpkin-cutter tool in their pant pocket and an approximate one-inch scratch mark on the inside of their left forearm (the skin was not bleeding). The pumpkin-cutter tool was previously stored in the R.E. Care Homes garage, which is usually locked and accessible only to facility staff via coded keypad entry. C1 obtained this tool when staff left them alone inside the facility’s garage to do laundry. C1 said they later went to their private bedroom at the facility and tried to slit their arm with the pumpkin-cutter, but the tool was not sharp enough to cause a laceration. R.E. Care Homes LLC staff were unaware of this attempt. C1 then took the tool to their day program, intending to try again and telling this to a peer. The peer quickly alerted the day program staff, who confiscated the pumpkin-cutter tool and notified R.E. Care Homes LLC management and the proper authorities/agencies.

Multiple interviews also showed that the day prior (on 07/22/2025), C1 had verbalized desire to self-harm to day program staff. Day program management telephoned this occurrence to R.E. Care Homes LLC management, providing them timely constructive knowledge. Per interview, the lone facility caregiver [Staff #1 (S1)] who was on duty and supervising C1 the next morning (on 07/23/2025) was not aware of and understanding of the verbalization which C1 made at day program just the day before.

The Department concluded that the pumpkin-cutter tool, in and of itself, was not a hazardous object, by virtue of its dulled, child-safe design, and as further evidenced by C1’s inability to lacerate their skin with it despite their earnest attempt. However, C1 and housemate interviews showed facility staff sometimes unlocked the garage-entry door to allow C1 and housemates to do laundry tasks. The staff sometimes did not remain inside the garage with the client to continuously supervise them.