Complaint Investigation Report

A review of C1’s medical records indicated that C1 had been diagnosed with autism spectrum disorder and had a history of sleep disturbances, paranoia, anxiety, and impulsive behavior, which sometimes resulted in frustration and anger. C1 was considered independent, highly functional, and capable of completing all activities of daily living with occasional prompts and reminders. C1 moved into the facility on February 5, 2024.

During an interview conducted on March 6, 2024, C1 described an incident in which S1 became upset after C1 disposed of a cell phone that had been purchased for them. C1 stated that they did not like or trust cell phones and never requested one. They admitted to discarding the phone and claimed that S1 became upset and pushed them during the argument. C1 noted they did not sustain any injuries and stated that the interaction was an argument, not a yelling match.

In a separate interview, S1 denied yelling at or pushing C1. S1 acknowledged feeling upset that C1 threw away the phone rather than returning it, but denied that any physical contact occurred. According to S1 and other staff, law enforcement was called during the incident because C1 attempted to strike S1, and staff were concerned for the safety of both C1 and others at the facility.

Staff interviews revealed that although they overheard an argument between C1 and S1 occurring in the garage, no staff directly witnessed the incident. Staff indicated that by the time law enforcement arrived, C1 had calmed down, and the situation had been successfully de-escalated. The incident was reported to both CCL and the placement agency as required.

A review of the facility’s incident report found no violations of Title 22 regulations. Additionally, a review of staff training records confirmed that all staff, including S1, had completed training in de-escalation techniques and personal rights.

Interviews with other clients consistently indicated that they had not witnessed staff yelling at or mistreating clients. Similarly, staff interviews revealed no reports of any mistreatment or abuse. C1 voluntarily moved out of the facility within the 30-day reappraisal period.