Complaint Investigation Report

On 02/10/26 at 12:30 p.m. and again on 03/20/26 at approximately 11:02 a.m., LPA inspected the dining room common area where client lockers are located. All locks were tested during both visits and found to be operational and secure. Staff reported that the facility has recently maintained a small supply of replacement locks. Facility had an unwritten policy regarding locker access which required that staff escort clients to their lockers. Facility is now putting this policy in writing going forward. However, staff acknowledged that at times they observed staff hand keys directly to clients, which they stated has contributed to lost keys and the need for lock replacements. Clients interviewed reported that staff typically walk them to their lockers and expressed no current concerns about accessing their lockers or obtaining their personal belongings.

During the 02/10/26 visit, while LPA was reviewing files in the HUB at approximately 12:15 p.m., a client approached requesting access to the sharps container. LPA observed the client holding approximately four to five disposable blue razors. Staff commented on the quantity. Staff interviews confirmed that facility standard has been to allow for razors to be issued and requires it be returned and disposed of immediately after use. Staff interviewed stated they were not aware of a formal tracking system for items such as razors, curling irons, or straighteners.

LPA reviewed the Telecare protocol #CS-1019-177 titled “Personal Belonging Check In and Check Out,” which states its purpose is to ensure that contraband or restricted items are issued, monitored, and stored safely. The protocol requires documentation of the date, time, and condition of items when checked out and when returned. When interviewed, staff stated there was no active check out list or consistent process in place, and responses varied regarding how items were monitored. Staff explained that items were issued and collected but agreed there was no formal mechanism to record or verify return.

Client interviews reflected mixed awareness of house rules but did not provide consistent concerns related to obtaining and returning contraband items.

Following identification that the check in/check out protocol was not being implemented as written, the Administrator created and stated they would implement a formal Check In/Check Out sheet to ensure appropriate tracking and documentation moving forward. As of visit on 3/20/26 staff interviewed had not been informed of the policy and tracking requirements. Continued on 9099-C