Complaint Investigation Report

On 10/20/2025 and 10/21/2025 LPA Marcella Tarin interviewed 3 Witnesses (W1 to W3). 3 out of 3 Witnesses state C1 reported that he/she was pulled out of the bathroom by S1 on 10/12/2025. W1 states C1 has behaviors of fixating on imagined stains for up to 30 minutes at a time and must be prompted and re-directed by staff. W2 stated over the past two months, he/she has observed C1 to have increased behaviors of fixating on imagined stains in the bathroom and C1 not following redirection. W3 states he/she was unable to get accurate details from C1 about this incident. W3 stated C1 has behaviors of being fixated on objects/things and being non-compliant with re-direction.

On 10/21/2025 LPA interviewed 3 Staff (S1 to S3). 2 Out of 3 staff state he/she did not observe the incident on 10/12/2025. S1 stated on 10/12/2025 C1 told him/her there was vomit near the bathroom toilet. S1 stated he/she and C1 walked toward the bathroom, when C2 entered the bathroom. S1 stated C1 and C2 walked into the bathroom at the same time. S1 states he/she did not observe any vomit in the bathroom. S1 stated he/she asked C1 to leave the bathroom because C2 needed to use the bathroom. S1 stated he/she asked C1 for a few minutes to leave the bathroom, and C1 was not responding to his/her verbal re-directions. S1 stated he/she attempted to re-direct C1 by pulling him/her by the sweater because C1 was not responding to verbal prompts, and C2 needed to use the bathroom. S1 stated at no time did he/she have any contact with C1’s hair during this incident. S1 stated the facility has 2 bathrooms (upstairs and downstairs) available to clients.

LPA interviewed C2. C2 stated on 10/12/2025 he/she and C1 walked into the bathroom at the same time. C2 states he/she thought C1 was walking toward the kitchen, but C1 “walked right into the bathroom in front of me.” C2 states he/she told C1 to get out of the bathroom, and C1 stood in front of the toilet. C2 stated he/she kept telling C1 “Get out, I have to use the bathroom” and C1 did not respond. C2 states when S1 pulled C1 by the sweater, C1 pulled back and forth with S1. C2 stated there is another bathroom upstairs, but he/she prefers the downstairs bathroom.

LPA toured the facility and observed the facility has 2 client bathrooms, with one bathroom being located on the facility first floor, and the second bathroom located upstairs. LPA observed 2 client bathrooms to be functional and available to clients in care.