LPA also obtained copies of and reviewed the following documents for C1: Individual Program Plan (IPP), Individual Behavior Support Plan (IBSP), Physician’s Report, 12/04/2024 Special Incident Report (SIR), ISP Data Collection from 01/01/2025, and Behavior Intervention Snapshot. Additionally, LPA reviewed the incident report that the facility provided to the Community Care Licensing Division (CCLD) when they self-reported an incident involving C1 and PM staff. On 01/10/2025, and 01/21/2025, LPA conducted collateral visits and interviewed three (3) staff members, including Staff #3 (S3). LPA also conducted telephonic interviews with Staff #1 (S1) at 1:14 p.m. on 01/14/2025, Staff #2 (S2) at 1:30 p.m. on 01/21/2025, and Staff #4 (S4) at 2:28 p.m. on 01/23/2025.

LPA review of C1’s IPP and IBSP revealed C1 can engage in unsafe behavior, such as hitting and biting others. C1 can also engage in self injurious behavior such biting and scratching themselves. On 12/04/2024 it was reported via SIR that C1 had swallowed an item causing the facility to implement a plan to remove items smaller than a tennis ball from C1 possessions. Review of SIR for 01/01/2025 the facility self reported an allegation had been made and on 01/01/2025, that identified S1, S2 and S3 as the staff that engaged in mistreatment of C1. LPA’s interview with C1, C1 affirmed the incident occurred as alleged involving the staff identified. LPA interview with two (2) other staff that were present on the day in question deny witnessing S1, S2 and S3 engaging with C1 as described in the allegation. LPA’s Interview with S1, S2 and S3 deny the allegation and corroborate C1 was engaging in unsafe behavior causing them to use blocking and redirection techniques and removing more items from C1’s room that they believed could cause harm to C1 or items C1 could swallow. Interviews with four (4) out of five (5) staff on shift and present on 01/01/2025 corroborate S2 did attempt to remove a tassel from C1's mouth but did not corroborate S2 had squeezed C1's cheeks excessively. LPA’s interview with the administrator, assistant administrator and four (4) randomly selected staff who worked on different shifts on the day in question and next day corroborate C1 disclosed to them the allegation at different times and the claim was consistent. Interviews with the four (4) randomly selected staff who worked on different shifts had not witnessed a prior incident as the one described in the allegation involving C1 and S1, S2 or S3.

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Exit interview conducted. Copy of report provided.