Complaint Investigation Report

The complaint further alleged that other clients would hit and pull C1’s hair, take away C1’s personal belongings, and that staff failed to take corrective or preventive measures to protect C1 from harm. Additionally, it was alledged that clients with aggressive behaviors took advantage of C1, who was described as friendly, calm, and easygoing.

An interview with an outside source revealed that they had not personally witnessed any incidents of abuse; rather, they became aware of the allegation through hearsay. Furthermore, no specific details regarding the alleged incidents were disclosed during the investigation. C1 was not available for an interview as they were no longer attending the day program.

On January 29, 2025, during a facility tour, clients were observed participating in group activities in groups of four (4) to five (5), with two (2) staff members supervising and guiding the activities. Clients appeared engaged and followed staff directions. Staff members were observed redirecting clients back to their activities when they stood up or wandered away from the table.

As part of the investigation, images and videos were submitted as evidence of the alleged abuse. A thorough review of the provided materials did not reveal any corroborating evidence to support the allegation that staff failed to provide a safe environment. Instead, the images and videos depicted clients participating in activities at the park and the facility, with no observed violations of personal rights or indications of physical abuse.

During staff interviews, it was consistently stated that clients were placed in groups with others who were behaviorally compatible. Staff reported that any clients displaying aggressive behavior were immediately redirected and, if necessary, removed from the group. Furthermore, staff consistently denied witnessing any mistreatment or physical abuse among clients or by staff members.

A detailed review of staff training records confirmed that all staff had completed the required training per Title 22 regulations, including personal rights, de-escalation techniques, and reporting requirements. Additionally, staff received specialized training on crossing streets with clients, boarding and unloading the facility van, seat belt requirements, and walking in public places such as parks, libraries, and malls.