Complaint Investigation Report

Additional staff accompanying another resident pulled over to offer assistance and de-escalation techniques, witnessing the event. R1 then began to lay on the street and bang his head on the asphalt until bleeding occurred. Report described "repeated blows to the head" and then called an ambulance for assistance. Interviews and record reviews further revealed R1’s history of head banging and other self injurious behaviors. On the day of this event, it was revealed that although staff attempted de-escalation techniques on R1, staff did not utilize protective equipment and other materials used to help prevent injuries. A review of individual behavior support plan revealed protective equipment may be used in the event of self injurious behavior. Additionally, on 6-28-25, it was a revealed through email communication that R1 sustained a rash on his lower extremities. Email communication between R1 and facility staff revealed that staff were not ensuring the regular and adequate placement of a special boot to be placed on R1’s foot, which led to the rash occurrence.

As a result of the above investigation, the preponderance of standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation of Section 80078(a) within a 12-month period. An exit interview was conducted with licensee designees and a copy of this report was provided via email with request for return with signature. Appeal rights and LIC 811 provided.