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32 | The investigation revealed the following: Regarding Allegation: Staff lock clients in their rooms. It is alleged all client doorknobs contain a keypad doorknob, clients may not be cognitive enough to enter combination code to enter their own rooms and clients are unable to exit their rooms from the inside. Two (2) out of the two (2) staff interviewed denied this allegation. C1 and C3 were not at the facility during visit and LPA Ramirez was unable to interview clients. C2 is non-verbal and LPA Ramirez was unable to interview client. LPA Ramirez toured the facility and observed one (1) out of three (3) client bedroom doors, to contain a keypad doorknob. LPA Ramirez observed a keypad doorknob on the outside of C1’s bedroom door. LPA Ramirez observed a doorknob on the inside of C1’s room and LPA Ramirez was able to exit C1’s room by turning the knob and exiting. LPA Ramirez was able to enter and exit C2 and C3’s room through bedroom door. Staff interviews revealed, C1 enters a 6-digit code to enter his room. This code is personalized and easy for C1 to remember. Staff revealed they have the code and will only use it if C1 presented a safety concern while locked in their room. Staff interviews revealed, C2 and C3 bedroom doors also had keypad doorknobs but on 2/3/2025, staff removed the keypad knobs at the request from Harbor Regional Center Staff. LPA Ramirez reviewed C1’s 1st quarter ISP and it indicated C1 can choose to keep their door ajar, or closed and locked if C1 chooses and staff will knock and knock and wait before entering. Review of C1’s IPP revealed C1 has a history of property destruction and entering his roommates’ room without permission and taking items without permission. C1’s IPP and ISP both indicate C1 is verbal and can communicate with staff. Review of C2’s IPP revealed C2 room has a lock with a code number to ensure C2 personal space is protected from housemates. C2’s IPP revealed C2 is non-verbal but communicates through gestures, facial expressions, noises, yelling/screaming, pointing, and leading. Staff interviews revealed, prior to 2/3/25, C2 would make noises to get staffs’ attention and lead staff to C2’s door and staff would enter a 6-digit code to allow C2 entry into their room. C3 is new to the facility and was admitted to the facility on 2/6/2025. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No violations were cited during this investigation. Exit interview was conducted. A copy of this report was provided via email. |