Complaint Investigation Report

Allegation #1: Staff did not prevent the residents from striking another person in the home with a weapon.

The complaint alleged that staff members did not prevent a client from striking another client in the home with a weapon. On October 2, 2025, at approximately 8:10 AM, LPA Richard interviewed Staff Member 1 (S1), who denied the allegation and stated that it was unlikely a client at the facility would hit another person with a weapon.

Simultaneously, LPA interviewed the Administrator (A1), who also denied the allegation, explaining that there was an incident involving the passing of a client due to complications of end-stage renal disease.

At around 8:30 AM on the same day, LPA interviewed six Clients, #2 through #7 (C2-C7); all six denied ever hitting another client with a weapon or witnessing any client hit another with a weapon. At approximately 11:00 am, LPA also interviewed the SDRC, who stated there were no concerns regarding the passing of C1 at the facility on 08/11/2022.

Additionally, LPA reviewed facility notes dated from August 02, 2022, to August 7, 2022, indicating C1 was happy and went to the movies. On August 10, 2022, C1 attended a dialysis appointment and came home very happy. On October 02, 2025, LPA received the concluding document of C1's passing, as per the death certificate dated 08/31/22, through an email from the SDRC caseworker about C1's passing on 08/11/2022.