Complaint Investigation Report

On 1/27/2023, during an outing at a restaurant, Client 1 (C1) informed staff that Client 2 (C2) followed C1 into the girl’s bathroom and tried to kiss C1, and tried to lick C1’s face. C1 told C2 to get out of the bathroom, and C2 exited. C1 later changed their story to include C2 inappropriately touched C1; however, witnesses interviewed indicate C1 has short-term memory problems and it was unusual for C1 to not mention it to anyone at the time but then mention it days later.

Through review of the staff schedule and interviews, LPA discovered there were 20 clients on the outing and 3 staff. LPA reviewed C1 and C2’s physician’s report and service plans. Records indicate both clients need supervision, but neither have a 1 on 1 staff. Tri-Counties Regional Center confirmed the ratio for this program is 6 clients to 1 staff. During the outing, the facility was out of ratio and did not provide adequate supervision to the clients, resulting in C2, a male client, entering the female bathroom and violating C1’s personal rights.

After the case management visit, the Program Director reviewed their processes for providing supervision to clients on outings to ensure they are in ratio and provide adequate supervision to clients.

Based on the information obtained, the allegation “Facility not providing a safe environment for clients” is deemed Substantiated at this time, as a lack of supervision led to C2 violating C1’s personal rights.

Exit interview conducted, deficiency cited, and the report and appeal rights given to the Administrator and Program Director.