Complaint Investigation Report

(PAGE 2 OF 3, CONTINUED FROM PAGE 1, LIC 9099)

A review of facility staff training records revealed that staff were required to take a substantial number of hours of online and in-person training regarding the care and supervision of clients. An interview with the facility Quality Assurance Director (QAD) revealed that since this facility is an Enhanced Behavioral Supports Home (EBSH), client behaviors tend to be very challenging, and clients may hit or bite individuals when they display behavioral issues. The QAD stated that this information is made clear to staff during interviews. The Department also conducted an unannounced facility visit on April 18, 2025, and found that there were a large number of staff present to work with clients. Training materials, as well as a flyer for the Ukeru method, a method used to deescalate behaviors, were also observed. The training method had recently been approved and staff were being trained on how to use the method. There is insufficient evidence to support this allegation.

It was also alleged that there wasn’t sufficient food or drinking water for clients. During the unannounced facility visit on April 18, 2025, it was observed that the facility had a substantial amount of food in two refrigerators and snacks in cabinets in the garage. It was also observed that there were large packets of bottles of drinking water. The interview with the DDS representative revealed that Client #1 (C1) has strong behavioral issues related to food and it was recommended that most of the food be stored in the garage. The DDS representative also stated that C1 tends to break glass and advised the facility to remove most of the food from a glass pantry located in the kitchen. An interview with the QAD also revealed that there are snacks and food available in the kitchen for clients, however, most of the food in the house is currently stored in the garage due to C1’s behaviors. A lead staff also has access to a food card that can be used to purchase food when needed. Water can be provided as bottles or through the water dispenser in the refrigerator. An interview with Client #2 (C2) verified that food was stored in the garage and not as easy to access, but C2 stated that they were still able to get their snacks and water when needed. There is insufficient evidence to support this allegation.

The Department has investigated the allegations that: staff were not properly trained, that staff did not ensure there was sufficient food for residents and that staff did not ensure there was sufficient drinking water for residents. Based upon the information obtained during this investigation, it is determined that the preponderance of evidence was not met to support or corroborate these allegations and they were therefore deemed unsubstantiated. (CONTINUED ON NEXT PAGE, LIC 9099C)