Complaint Investigation Report

R1’s Admission Agreement indicates R1 was admitted to the facility on 05/10/2023. The email communication with staff S1 indicates R1 was discharged from the facility on 06/26/2023.

LPA Marrufo reviewed R1’s Residential Progress Notes. R1’s Progress Notes have entries dated from 05/10/2023 to 06/26/2023. Each daily Residential Progress Note from 05/10/2023 until 06/24/2023 showed that R1 neither reported nor was observed to have had a suicidal ideation. R1’s Residential Progress Note for 06/25/2023 does not indicate whether R1 reported or was observed to have had a suicidal ideation. R1’s Residential Progress Note from 06/26/2023 at 1:27 PM states that R1 did not report nor was observed to have had a suicidal ideation. R1’s Progress Note from 06/26/2023 at 5:30 PM states R1 felt ready to move to the next facility. The note states R1 reported some continued daily passive suicidal ideation and denied current intent. The note also states R1 denied self-harm urges.

During visit on 10/02/2024, LPA Marrufo interviewed S1. S1 stated that passive suicidal ideation is when an individual has thoughts of suicidal ideation but does not have a plan. LPA Marrufo asked S1 why the last entry of R1’s Residential Progress Notes state that R1 had continued suicidal ideation, but all the previous entries state that R1 neither reported nor was observed to have had suicidal ideation. S1 stated that S1 could only guess that perhaps R1 had a different relationship to the staff who wrote the last entry in R1’s Residential Progress Notes than R1 had with the staff who wrote the other entries.

During visit on 10/02/2024, LPA Marrufo interviewed S2. During interview, S2 stated that the facility where R1 was being transferred to on 06/26/2023 is an independent living facility for men. S2 stated the independent living facility allows the admittance of residents who express passive suicidal ideation, but not active suicidal ideation. S2 stated that La Selva also only permits residents with passive suicidal ideation and if a resident is found to have active suicidal ideation, then the resident would be hospitalized.

R1’s Admission Agreement does not make any mention of drug testing of residents.

R1’s La Selva Dually Diagnosed Track Requirements document states that one of the requirements includes “Random drug tests while at the program via U.A. test.”