complaint·August 11, 2021

Throughout LPA Colvin's investigation, LPA Colvin confirmed that the altercation between R1 and R2 did take place and that the police were later called out and detained R1. The altercation consisted of R1 putting R2 in a head lock with their arms, pinning R2 to the wall, and taking R2 to the ground and restraining R2 there for a period of time. Through interviews conducted, LPA Colvin learned that there was no immediate staff intervention done by staff during the incident or prior as the argument between residents was escalating. Additionally, LPA Colvin was informed that after the incident, no additional mental health treatment, assistance, or evaluation, was sought for R1 by the Administrator. During LPA Colvin's investigation, she was provided with a document which claimed to be an eviction notice for R1, which was dated for 4/29/20. However, this Eviction Notice was not carried out, as R1 did not move out of the facility until December 2020. Furthermore, no documentation of this Eviction Notice was provided to Licensing, and it was not readily available in R1's file or for LPA Colvin to review during a physical inspection of the facility and was provided to her electronically later by facility staff. Lastly, the validity of the Eviction Notice is in question as LPA Colvin interviewed outside parties in relation to R1's move from the facility, and no one interviewed other than facility staff could verify that R1 was ever given an eviction notice or asked to leave the facility. The Licensee failed to address the physical altercation between R1 and R2 adequately by either seeking additional assistance from mental health (such as an evaluation or increase of services), knew that R1 was diagnosed with a mental health diagnosis and had been refusing medication and treatment, and failed to provide/enforce an eviction notice for R1 when R1 violated the facility's rules and posed a safety risk to other residents. Additionally, staff failed to provide adequate supervision to residents as it was reported in LPA Colvin's investigation by multiple persons that R1 was showing signs of odd behavior prior to the incident between R1 and R2, and both staff members on duty were in the kitchen cooking and not providing supervision to the residents when the altercation occurred. Based on LPA Colvin's interviews and records review, the allegation of "Facility staff are not keeping residents safe" is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. Due to observations made by LPA Colvin, the facility was cited, and deficiency noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of this report was provided to Designated Facility Representative Adam Ahmad "Adam" Abdallatef during the exit interview, and LPA Colvin will be emailing a copy of the report to Administrator/Licensee Najeh "Nick" Hamed as well.