Client is being restrained resulting in bruising.- UNSUBSTANTIATED

It was reported that Client 1 (C1) had bruises up and down their arms which did not appear to be self-inflicted due to RP’s historical experience with C1. RP suspects bruising may be caused by restraint.

LPA viewed photographs of C1 that were taken at the facility when C1 arrived home from their day program on 03/18/2026. These photographs show C1 has black right eye and large bump on forehead and bruising and scratches on their stomach. Day program staff reported that C1 engaged in a significant amount of self-injurious behavior (SIB), resulting in visible scratches on their stomach. C1 also repeatedly banged their head against the wall, causing visible marks on their forehead and right eyebrow. Staff care notes for the day state C1 came home from program with a huge bump on side of their head by their eye and had a black eye and scratches on their belly.

Staff care notes dated 03/19/2026 report that C1 was pulling their hair and tried to bite themselves.

LPA viewed photographs dated 03/20/2026 which show that C1 had a large scrape on their right knee and a cut on their left middle finger. Staff care notes on 03/20/2026 report that C1 arrived home from program with blood on their hands and face from a cut on their finger. C1 also had a scraped knee in the photos. Email sent on 03/20/2026 from day program to facility report that C1 had some open wounds and bleeding.

Staff care notes dated 03/29/2026 report C1 began harming and hitting themselves. Notes on 03/31/2026 state C1 had a bite mark and was bleeding. The same day, program had said C1 had bitten themselves.

Narrative continued on LIC9099-C

Day program reported the following to facility concerning C1: 03/31/2026 Self-injurious behavior at the end of the day. 04/13/26 C1 self-injuring. 04/08/2026 C1 hitting, and biting themself, which continued on and off all day. The only marks visible are bruises on their hands from biting and a mark on their head from hitting it on the wall.

All staff stated that C1 is never restrained in the home. If C1 is behavioral at home, staff will re-direct them by going for a walk or a car ride with C1.

Day program administrator stated that all clients who attend the program sign a form acknowledging the program is “hands on.” Day program staff really don’t do any aggressive hands on with C1 because C1 bites themselves and does a lot of self-injury.

Facility administrator stated the home is a “hands-off” facility and clients are never restrained.

It was determined that C1 does express self-injurious behaviors often. House staff re-direct C1 from injuring themselves without using restraint in the home. The day program that C1attends had reported and documented multiple instances of self-injurious behavior by C1. This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that C1 is not being brought into their day program wearing appropriate attire. C1 was wearing a coat when it was hot outside. C1 wears clothes that are too small or not appropriate for the season.

LPA reviewed C1’s Individual Program Plan (IPP) which states C1 requires staff support in bathing and dressing. C1 is able to pick out which clothes they like to wear for the day by gesturing to different things they like. Care notes dated 03/23/2026 state C1 had no issues changing but kept putting a sweater on despite staff talking about the heat that day.

On 04/14/2026 LPA toured the facility and observed that C1 has a closet and dresser that contains clothing for all seasons. The amount of clothing is sufficient and all clothing is in good repair.

All staff stated that C1 picks out their own clothes every day. C1’s clothes are the appropriate size. C1 has clothes for all seasons but often requests to wear a jacket even when the outside temperature is warm.

Day program administrator stated that C1 gets really messy when they eat and sometimes they run out of the extra clothes that are sent in with C1 to program so the program will provide clothing to C1.

Facility administrator stated that C1 selects their own clothing every day. C1 is cold the majority of the year and sometimes even though it is hot outside C1 chooses to wear a sweater.

This allegation is unsubstantiated.

Continued on LIC9099-C

It was reported that C1 may not be taken to see their doctor as needed.

LPA reviewed documentation of medical appointments that C1 attended on 03/19/2026, 03/31/2026, 04/02/2026, and 04/07/2026.

All staff stated that C1 goes to regular doctor’s appointments.

Facility administrator stated C1 goes to see their primary care physician every couple of months and behavioral health appointments regularly.

This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Chantelle Browning.