Complaint Investigation Report

Department Interview with outside source revealed that R1 and R2 have been roommates since May 2025 and that no prior issues between the two residents had been reported before this incident.

Department Interviews with Staff #1 and Staff #2 revealed that Staff #2 was inside the room cleaning when the incident occurred and witnessed R1 strike R2. Staff reported they immediately called for assistance, responded at once, separated the residents, and de escalated the situation. Staff also reported that R1 appeared confused.

Department record review revealed both residents were assessed with no injuries noted, responsible parties were notified, and R1 was transported to hospital for further evaluation.

Based on interviews and records, the preponderance of evidence does not support that staff failed to provide adequate supervision. Staff were present, witnessed the event, and intervened promptly. Therefore, the allegation is UNSUBSTANTIATED

An exit interview was conducted with Executive Director Carlborg , to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.