Complaint Investigation Report

LPA Marrufo obtained a copy of resident R1’s Appraisal/Needs and Services Plan. R1’s Appraisal/Needs and Services Plan states R1 “experiences frequent sexual preoccupation with peers and staff, and has repeatedly reported that auditory hallucinations influence these decisions.” The document states R1’s socialization needs are to “maintain and respect boundaries of staff and other residents.” The methods of evaluating R1’s socialization progress is stated as “Staff observations, self-report, weekly meeting with case manager.” The document states R1’s mental needs as “minimize psychiatric symptoms” and the method of evaluating R1’s mental needs progress as “Staff observations, self-report, monthly meetings with psychiatrist.”

Administrator (ADM) Ariel Palencia provided LPA Marrufo with forwarded emails between and R1’s psychiatrist. In an email from 12/08/2023, ADM notified R1’s psychiatrist that ADM will get newly prescribed medication for R1. In another email form 05/03/2024, ADM stated ADM stated R1’s labs were taken the day before and was requesting for R1’s psychiatrist to upload the lab results. Microsoft Teams conference invites were sent in emails from 01/25/2023 and 06/06/2023 between ADM and R1’s behavioral management team. In an email from 08/01/2023, R1’s psychiatrist provided ADM with instructions on how to prepare R1 for labs that were scheduled to occur on 08/15/2023.

LPA Marrufo interviewed R1 on 04/09/2024. During interview, R1 stated that ADM told R1 not to touch people. R1 stated that ADM told R1 not to touch people as recently as a couple days prior to the interview. R1 stated to not remember if ADM told R1 not to touch any particular person.

LPA Marrufo conducted a telephone interview with resident R2 on 05/03/2023. R2 stated during interview to prefer not to speak to LPA Marrufo.

During interview on 04/09/2024, ADM stated that R1 and R2 used to live in adjacent bedrooms in the facility. ADM stated that R2 complained to ADM that R1 knocked on R2’s bedroom door in the middle of the night. ADM stated to have interviewed R1 about the incident, and R1 stated to have knocked on R2’s door to ask for cigarettes.