Complaint Investigation Report

On 03/24/2026, LPA along with the QAS conducted an initial 10-day complaint visit to investigate the above allegation. At approximately 09:30 a.m. LPA conducted a tour of the physical plant, interviewed staff, clients, and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 05/05/2026, LPA reviewed Police body cam footage of the 03/19/2026 incident between approximately 02:03:35 p.m. to 02:05:30 p.m.

It was reported that “Staff did not prevent client from pushing someone”, “Staff did not prevent a client from punching others”, “Client sustained injuries due to staff neglect” and “Staff did not ensure client had clothing items on” as It was alleged that, due to staff neglect, Client #1 (C1) pushed an individual, punched others, sustained an injury and removed articles of clothing. Interviews and record reviews indicated that on 03/19/2026, C1 left the day program after becoming upset when they overheard two individuals arguing. As a result, C1 became agitated and walked away from the facility. Staff #1 (S1) attempted to redirect C1, however, C1 did not respond to S1's efforts and continued walking toward a nearby 7-Eleven. S1 maintained visual supervision and followed C1 at a safe distance. During this time, C1 began swinging their arms in S1's direction. S1 continued monitoring C1 while maintaining an appropriate distance. C1 eventually stopped at a nearby gas station. The 7-Eleven and gas station are located within the same parking lot as the facility. Witnesses in the area observed the situation and began yelling at C1. In response, C1 yelled back, displayed self-injurious behavior and picked up nearby objects such as bottles and a tree branch, which were subsequently thrown in the direction of the bystanders. C1 then removed their shoes, socks, and shirt. S1 informed the bystanders that C1 was under staff supervision and that assistance was being provided.

Additional staff arrived to assist. Law enforcement and C1's family/responsible parties were notified. Staff continued to supervise and monitor C1 until law enforcement arrived on scene. Staff members who responded to provide assistance reported that the Administrator arrived shortly after law enforcement and began speaking with C1. LPA’s interview with eight (8) staff members, including two (2) staff who were present during the incident, and six (6) clients reflected that all individuals did not express concerns regarding staff supervision or staff's response to the incident. Individuals reported no concerns that staff ever failed to prevent individuals from being pushed, punched, or otherwise harmed. Additionally, interviewees did not report concerns regarding staff's supervision of individuals who were not fully clothed during the incident.