Complaint Investigation Report

During interviews, it was reported that two staff members were fighting in the back yard of the facility. It was reported during the fight that a section of the wood fence facing southwest was broken and knocked to the ground. It was reported that the fence was picked up off the ground and put back in place. It was reported that R1 witnessed the altercation.

During staff interviews It was reported two staff members were just messing around, S3 stated when S4 was getting out of the headlock hold, S4 fell against the fence and it broke. S3 stated one of the clients may have witnessed the altercation. It was reported that R1 did witness the altercation. It was reported that the altercation was recorded on a staffs' phone.

Record review revealed an incident report dated February 15, 2026 at 8:00 p.m. stated that a client was outside smoking, lost his balance then fell against the fence with his shoulder, breaking a fence board.

While reviewing client’s Individual Program Plan (IPP) it was noted that it is important that R1 has constant supervision due to physical aggression. It was reported during the altercation (physical aggression) two staff members were in an altercation and the other staff member was recording it, staff were not supervising R1.

Based on investigation observations, record review(s) and interviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated . California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Appeal rights were explained and provided to the facility representative listed above and exit interview conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.