Complaint Investigation Report

to focus more on R1's room as R2 used to be R1's roommate. The administrator stated he told staff that once R1 was not in their room they could block the door utilizing the spare bed in the room so R2 could not enter. However, R2 figured out how to get around the blockade by entering the adjacent room and going through the Jack and Jill bathroom. They decided to stop blocking the door and they have not used the bed to block the door since that started happening. Staff stated now they keep a closer eye on R2 and redirect R2 when necessary. R2 also takes their current roommate's property and tries to pack it up. Staff keep most of the property belonging to R2's current roommate stored across the hall in the locked laundry area.

Based on interviews with staff, R1's shoe laces were observed to be wrapped around part of the foot rest on R1's wheelchair. R1's visitor had reported to staff they had observed this on more than one occasion. On the day R1's visitor reported this, Staff 2 (S2) took a photo of R1's shoes secured to each foot rest. The staff who were interviewed stated they observed this happened after Staff 1 (S1) had provided R1 with care and before the next shift provided care to R1. S1 stated in the interview that they had not noticed R1's shoe laces around the foot rest and thought it may have happened accidentally. However, the administrator stated he spoke with S1 and S1 initially stated they did not know how it happened but later in a second conversation with administrator admitted to securing R1's laces to the wheelchair foot rests.

Based on these interviews, the above noted allegations are deemed SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Exit Interview conducted. A copy of the report and appeal rights were issued.