Complaint Investigation Report

Allegation #1: Staff abandoned the residents at the hospital.

The complaint alleged that law enforcement brought the client to the hospital under a 5150 hold. On April 9, 2026, the department interviewed the Administrator (A1), who denied the allegation. A1 explained that on April 24, 2024, the Community Integrated Program discontinued services for client #1 (C1) due to safety concerns. C1 had unbuckled their seat-belt while the vehicle was on the freeway. Also, C1 attempted to pinch the driver while driving.

When C1 arrived at the facility, C1 was very upset and aggressive, prompting a call to Emergency Services, who then transported C1 to the hospital under a 5150 hold. On April 25, 2024, the hospital contacted the facility to request that they pick up the client. Upon arrival at the hospital, C1 was extremely agitated and out of control. Due to this aggressive behavior, both towards the hospital staff and the facility staff, A1 decided to leave C1 at the hospital for further care, as the client was also medically and physically restrained. A1 noted that the facility continued to visit C1 throughout C1's hospital stay.

On April 29, 2024, C1 was deemed fit for discharge, and the facility picked C1 up from the hospital. On the same day, the department interviewed one staff member (S1), who confirmed that C1 is very aggressive, has physically assaulted staff members, and often does not remain seated with their seatbelt fastened in the vehicle. The department also spoke with three other clients (C2-C4), all of whom stated that they enjoy living at the facility and that the staff takes them to all their appointments.

The department also reviewed the Whole Person Assessment (WPA), which confirmed that the client had multiple 5150 holds due to aggressive behavior. The department received a copy of the Unusual Incident Report submitted by the facility to the Community Care Licensing Department (CCLD) on 04/24/24 regarding the incident that occurred that day. The department also received a copy of the recommendation from the Behavior consultant dated 09/13/24, which limited the client's outing due to behavior while traveling in a vehicle.