Complaint Investigation Report

On January 21, 2026 and on May 08, 2026 LPA conducted interviews with facility staff.

Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), and Staff 6 (S6) stated they did not witness staff physically abuse R2.

Based on interview of S2, S3 and S6 who stated that R2 has a history of self injurious behavior, including striking own chest during behavioral episodes. S6 stated that on January 11, 2026, he/she observed R2 engaged in an aggressive behavioral episode and repeatedly struck his/her own chest, resulting in bruising. S4 stated that during a subsequent overnight shift, bruising was observed on R2’s chest. S4 stated that R2 initially stated not knowing how the bruising occurred, then stated being hit, but did not identify who caused the injury. S3 stated that R2 has a history of attributing injuries to others during behavioral episodes.

On January 21, 2026, LPA reviewed R2’s file record, including the Behavioral Support Plan, Client Development Evaluation Report, Individual Program Plan, Person-Centered Program Plan, daily notes, and pre-placement records. Based on document review, R2 has diagnosis of intermittent explosive disorder, history of physical aggression toward staff and peers, self injurious behaviors including striking own chest, and a prior documented incident in which R2 engaged in self injurious behavior and attributed the injury to staff. Record review further documented R2’s need for close supervision due to aggressive and maladaptive behaviors.

Based on record reviews, and interviews, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that staff physically abused the resident if the incident did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted and a copy of the report was provided to Administrator (ADM) Jhanelle Guico.

On 06/16/2026, and 07/03/2026 , On 06/16/2026, LPA attempted to interview Resident 2 (R2); however, R2 declined to participate despite three attempts by facility staff to obtain R2's consent. LPA interviewed Resident 3 (R3), who denied observing staff physically harm R2 or any other resident and denied being physically harmed by staff. On 07/03/2026 , LPA interviewed Resident 2 (R2). R2 stated that staff and residents were hurting R2 and stated that staff pushed R2 and hit R2 on the knee. During the interview, R2 identified multiple staff and residents as causing injuries. LPA observed a superficial scratch on R2's knee with no visible bruising or limping. During the visit, LPA observed R2 approach another resident without physical contact and observed staff and residents maintaining distance from R2. When asked about Staff 4 (S4), R2 stated not remembering S4 . However, R2 repeatedly referred to S4 as "correcto," but was unable to explain the statement. page 2 of 2 - end of report