05/21/2020, and conducted staff interviews on the following dates: 05/29/2020, 06/01/2020, 06/02/2020. Throughout the course of the investigation, LPA reviewed relevant documents. The following was then determined:

Regarding the allegation “Staff handled client inappropriately:”

It was alleged that during a behavior incident involving Client #1 (C1) that staff utilized a physical intervention inappropriately. LPA conducted interviews with staff and clients, but C1 was unable to be interviewed, as C1 moved out of the facility prior to an in-person interview being conducted. The incident occurred during the overnight shift, which extended from 10:00PM 10/11/2020 to 06:00AM 10/12/2020. Sometime around 11:00PM, C1 entered the kitchen requesting juice from the staff. Staff told C1 they were unable to have juice, either because it was too late at night for juice or there was none of the juice C1 requested in the facility. The response from staff agitated C1 and C1 began verbally engaging with the staff. One staff (Staff #1 – S1) was able to speak to C1 and calm them, offer C1 an alternate drink, and C1 returned to their room. When C1 returned to the kitchen, staff were sitting and laughing, which agitated C1. C1 ran at Staff #2 (S2) and Staff #3 (S3) and Staff #4 (S4) intervened. Witnesses indicated that S2 and S3 pushed C1 against the kitchen counter. S4 then put C1 into a chokehold and S2 held C1’s arms behind their back, resulting in C1 biting S4 in the stomach. S2 and S4 got C1 down to the ground and held C1 while the police were called. Witnesses also indicated that S2 had their knee and bodyweight on C1’s back, while pushing C1 down and holding C1 on the ground. Police report reviewed confirmed that when police arrived at the facility, both S2 and S4 were holding C1 on the ground, with C1’s arms held behind their back. During an interview with police on scene, S4 indicated they “pushed [C1] up against the sink. Staff [S2] grabbed C1’s arms and held them behind C1. Report reviewed indicates police were called at 11:02PM and C1 was arrested at 11:45PM. All staff and witnesses indicated that C1 was held from the time staff called the police until the time police arrived at the facility and handcuffed C1. Additionally, staff interviews revealed that during the incident on 05/18/2020, Staff #5 (S5) placed Client #2 (C2) in a one person hold. Staff #6 (S6), who witnessed the hold, indicated that S5 grabbed both of C2's arms and S5 pushed C2 down into a chair and held C2. Administrator indicated that S5's actions were uncalled for and S5 should never have put C2 in a hold on their own. Therefore, based on interview and record review, the allegation that “staff handled client inappropriately” is deemed SUBSTANTIATED at this time.

Continued on LIC 9099-C

Regarding the allegation “staff does not speak to client with dignity and respect:”

It was alleged that during the above indicated incident, staff did not speak to client appropriately, as well as the overnight staff not speaking with Client #3 (C3) appropriately. Staff interviews revealed that S2, S3, and S4 who frequently work the overnight shift taunt and tease the clients, including C1 and C3. During the incident described above, it was reported by witnesses that the staff were yelling at C1 when they asked for juice and then were laughing and talking about C1 when C1 walked back into the room. Additionally, interview revealed that on 10/29/2020, Staff #7 (S7) was witnessed yelling at C3 outside and threatening C3 stating that C3 “needs to stop lying." S3 was witnessed telling C3 “you need to stop lying. You’re a liar.” A witness also reported they walked in as S3 was singing a song and mimicking C3. Therefore, based on interview, the allegation that “staff does not speak to client with dignity and respect” is deemed SUBSTANTIATED at this time.

Regarding the allegation “facility staff has not received required training:”

The complaint alleges that facility staff have not been trained in CPI prior to beginning work at the facility. District Manager contacted LPA on 10/09/2020 to confirm S1 was cleared and associated to the facility. The incident involving C1 occurred during the overnight shift on 10/11/2020. Interview revealed that when the incident occurred, S1 did not have their CPI training. In fact, S1 indicated they did not complete the required training until 11/22/2020. According to People’s Care Behavioral Risk and Mitigation Plan reviewed, “each staff is trained in CPI and is encouraged to always use the least restrictive technique or procedure in order to de-escalate a situation and assist an individual in crisis.” During an interview with the substitute Administrator, it was stated that “it’s a mess over here and [substitute Administrator] has been trying to clear up all the paperwork.” LPA requested training documents at the time of the initial complaint visit, but those records were not submitted to CCL. Additionally, S6, who was working on 05/18/2020 during the time of the incident involving C2, was not trained yet and therefore unable to assist S5 in a CPI hold. During a subsequent complaint visit conducted on 03/28/2023, LPA reviewed training documents for 3 (three) staff who were hired and employed during the time period of the incident and complaint allegation. Record review revealed two of the three staff reviewed did not have the required 16 hours initial CPI training. Therefore, based on record review and interview, the allegation that “facility staff has not received required training” is deemed SUBSTANTIATED at this time. Report Continued on LIC 9099-C

The following deficiencies were observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Lead Staff was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Belen Gutierrez. A copy of the report and appeal rights were provided.