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13 | On 12/03/25, at 9:10 AM, Licensing Program Analyst (LPA) Andrea Aceves made an unannounced visit to the above facility to deliver an amendment to the findings on the above allegations. LPA Andrea met with Lead/Facility Manager Ellen Reece.
During the investigation, LPA Andrea interviewed all available parties and reviewed LIC500-Personnel Report, Incident Reports (IRs), Needs and Services Plan, and Post Restraint Review Report. It was reported that (1) “Staff used an excessive restraint to minor in care.”. Based on interview statements and Incident Report dated 07/31/25, LPA Andrea was able to confirm that staff did restrain C1 however, LPA was unable to find sufficient evidence to support that minor was dropped aggressively to the floor. In addition, per Post Restraint Review Report, LPA confirmed that staff used de-escalation techniques on C1 to no avail. Due to safety concerns for C1 having a screw and throwing rocks at staff, facility staff initiated a restraint on C1, while C1 was sitting on the ground. C1 sought medical attention following the incident for any injuries. C1 refused to be assessed by medical staff, however, the nurse did not observe any visible injuries. The nurse followed up the following day, C1 denied any injuries but reported mild body ache which was treated with medication. Based on the evidence, LPA could not confirm if excessive restraint was performed. As a result, this investigation is being closed.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore, the allegation is unsubstantiated.
Exit interview was completed and copy of the report and appeal rights were discussed and provided to Lead/Facility Manager Ellen Reece.
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