Complaint Investigation Report

Interviews revealed on September 25, 2021 that Client 1(C1) called the administrator to ask about a visit with their family and found out the visit was for the next weekend. Interviews revealed Client 2 (C2) asked C1 about visiting their family. C1 got agitated with C2 and jumped on C2. C1 began to choke C2, pull C2’s hair, and bit C2 in the face causing injury on left cheek and on the left hand. Staff was able to separate the two and 911 was called. Interviews revealed staff sent C2 to their room and stayed with C1 until police arrived. The police department with PERT (Psychiatric Emergency Response Team) arrived. Interviews revealed both clients were escorted to the hospital. C1 was sent to the behavioral unit on a 51/50 hold and C2 was sent to be observed by medical staff for their injuries.

It was alleged that staff did not prevent residents from engaging in a physical altercation. Interviews revealed the two clients were in the living room and the staff was in the kitchen doing the dishes. Individual Program Plan for C2 revealed that C2 needs 24/7 supervision and line of sight supervision. Interviews with staff revealed that on 09/25/2021, staff heard C2 scream which is usual for C2 since C2 screams for attention. When the staff walked into the living room, staff observed the altercation between the clients. C2 kicked C1 and C1 kicked C2 back and began to pull C2s hair and choke them. Staff didn’t prevent the altercation from occurring due to staff being in the kitchen at the time and not supervising the clients.

Based on the evidence obtained from the investigation, the above-mentioned allegations are substantiated. The allegations are valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Raquel Garcia. A copy of this report and Licensee Appeal Rights (9058 01/16) were emailed to Administrator after the conclusion of the visit, LPA Holmes requested an electronic message reply to confirm receipt of these documents.