Staff additionally informed that C1's behaviors exceeded the resources of the facility and that C1 required a higher level of care than the facility could provide. During the investigation staff confirmed that a higher needs facility placement was secured for C1. Staff consistently stated that the training was sufficient for the clientele the facility served.

LPA was unable to interview C1 during the facility visits. During unannounced facility visit on 04/17/2025, C1 presented with two significant behavior episodes resulting in staff initiating C1's behavior protocol plan twice. LPA observed C1 push past the delayed egress without staff supervision during both episodes and refuse to return back to the home. During one of these events C1 entered the facility van, locked themselves in from the inside, and attempted to break a window with a flashlight. LPA made a second unannounced facility visit to attempt to speak to C1, however C1 no longer lived in the home, having been relocated to a facility that offered a higher level of care. Interview with additional clients revealed no concerns regarding staff training or elopement protocols.

Two outside sources were interviewed regarding the allegation. An outside source from a protective agency familiar with the facility (OS1) expressed concerns regarding the number of elopement emergencies the facility was having for C1 and believed staff needed more training to prevent inadvertently exacerbating C1's behaviors. A second outside source from a placement agency familiar with the facility (OS2) stated that they had no concerns regarding staff training, and that the facility went above and beyond to meet the needs of C1. OS2 additionally stated that C1's behaviors exceeded the type of care and intervention the facility could provide, and that C1 required a higher level of care.

Records review showed that staff was given training to meet the needs of clients that the facility is licensed to serve. Records additionally also showed that C1's behaviors were greater than the level of care that the facility was able to provide, and that the facility took action to assist in finding C1 a placement that could handle C1's higher care needs.

LPA Patterson directly observed two behavior incidents with C1 during an unannounced facility visit on 04/17/2025. Both incidents resulted in C1 advancing past the delayed egress and into the driveway. LPA observed staff conduct consistent elopement procedures by notifying staff over the walkie, positioning themselves within required ratio to observe C1 from a distance, and attempting to de-escalate.

(Continued on LIC9099 p.3)

LPA observed staff prepare equipment for an approved hold in the event that C1 became a danger to themselves. The protocols enacted by staff during these incidents were consistent with the behavior protocols detailed by staff during interviews and protocols listed in records review. During this unannounced facility visit, three staff members enacted a mock display of a Crisis Prevention Intervention (CPI) hold (with staff standing in as a client having a behavior incident) to show the procedure. Each staff took turns verbally/physically detailing the types of holds and rules, including time restrictions and what is not allowed. The display showed staff's thorough understanding of maneuvers and LPA did not detect any inconsistencies among staff regarding the appropriate steps for intervention. LPA's direct observations did not corroborate the allegation, as staff evidenced having behavior training, which was consistent with statements provided by staff during interview. The evidence shows that while C1 exhibited consistent severe behaviors while living at the facility and was found to ultimately need a higher level of care, staff were adequately trained to meet the needs of clients within the facility's scope.

It was alleged that staff did not follow elopement protocol for C1. During interviews staff members consistently detailed the facility's elopement procedures. Staff informed that C1 attempted to leave the facility by bypassing the delayed egress numerous times per day. The protocols detailed by staff during interview were directly observed by LPA when C1 eloped twice during LPA's facility visit. Staff interviews further revealed that due to C1's extreme behaviors, new, more refined protocols were put in place to reduce C1's elopements. Staff informed that the protocols were effective.

LPA was unable to interview C1 privately during the facility visit. C1 attempted two elopements during LPA's visit resulting in staff initiating C1's behavior protocol plan specific to elopements. LPA observed C1 push past the delayed egress without staff supervision twice during the facility visit and refuse to return back to the facility. LPA observed staff communicate over the walkie talkies that an elopement had occurred, and position themselves in the required ratio to observe C1 from a distance, and attempt to de-escalate. The protocols enacted by staff during these incidents were consistent with the elopement protocols detailed by staff during interviews, and protocols listed in records review. LPA's direct observations did not corroborate the allegation, as staff exhibited the required protocols during C1's elopements. LPA made a second unannounced facility visit to attempt to speak to C1, however C1 no longer lived in the home, having been relocated to a crisis home that offered a higher level of care. Additional clients interviewed stated they had no concerns regarding elopement protocols. (Continued on LIC9099 p.4)

Two outside sources were interviewed regarding the allegation. An outside source from a protective agency familiar with the facility (OS1) expressed concerns regarding staff interactions with C1 during elopements, expressing concern that staff aggravated C1's behaviors in an attempt to get C1 to return to the facility. A second outside source from a placement agency familiar with the facility (OS2) informed that staff were highly trained with the elopement protocol for C1 and that staff went above and beyond when handling C1's behaviors. OS2 stated they did not have concerns about staff's handling of C1's elopements.