Complaint Investigation Report

Staff interviews revealed that client C1 was observed on the roof while smoking a cigarette, on July 17. 2025. During multiple interviews, staff explained that they received a phone call from an outside source making derogatory remarks toward the facility, stating that there was a client on the roof.

Staff stated that they immediately went upstairs to Room 2, where C1 was staying, and observed C1 outside on the roof. Staff instructed C1 to come back inside, and C1 complied. C1 explained to staff that they were clearing their head after having been triggered earlier by the same outside source that reported the incident while they were sweeping the patio. Review of records and staff interviews did not reveal evidence of inadequate supervision. Instead, records and interviews showed that staff responded immediately, redirected C1 safely back inside, and ensured that the client was unharmed. Review of C1’s records and progress notes did not indicate that C1 was exhibiting health or safety risk behaviors or attempting self-harm. Staff rounds logs confirmed that safety checks were conducted every 30 minutes as required. Based on the information obtained, there was no evidence to support that the C1’s presence on the roof was caused by inadequate supervision. Staff responded promptly, redirected C1 safely back inside, and ensured the client was unharmed.

During interviews, staff reported that client C2 exhibited behaviors that threatened their health and safety, on June 26,2025. Staff activated 911 emergency procedures, and law enforcement responded to the facility. C2 was transported to the hospital on a 5150 psychiatric hold for further evaluation and treatment to meet their needs. Contrary to the allegation, C2 was not taken into custody. Records confirmed staff provided immediate intervention to prevent self-harm and acted appropriately.

Based on review of records, staff interviews, and observations, there was no evidence that either incident was the result of inadequate supervision. Staff actions were timely and consistent with Title 22 requirements.