Severe reports

Individual #1 was able to obtain large quantities of each medication from Employee #1’s personal belongings, and later ingest these medications while on the unit, which resulted in the individual being hospitalized and whom later died.

Therefore, Individual #1 had an opportunity to ingest Employee #1’s medications, which resulted in the individual being hospitalized, and whom later died.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-46-60. K. Providers shall not engage in willful action or gross negligence that jeopardizes the care or protection of residents.; 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;.

Sexual abuse includes threatened sexual abuse).

From the state's report. Maltreatment determined as to neglect of an alleged victim by a staff person..

During the investigation it was found that a staff member used excessive physical force and slapped a child in care, putting them at risk for physical injury.

During the investigation it was found that a staff member hit a child in care on the back of the head.

During the investigation it was found that a staff member improperly restrained a child in care by holding the child around the neck with the child's hands behind their back

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work.; 748.2605(a)(2) - Personal Restraints Prohibited-Restraints that obstruct child's airway.

In an investigation conducted by DFPS, two staff were found reason to believe for physical abuse of a child.

Staff was observed via the EBI video, using excessive force when he lifted the child off of the ground during a restraint, causing the child's feet to drag; consequently, causing both child and staff to fall to the ground and injuring the child's foot.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation; 748.2551(c)(2) - EBI Implementation-Caregiver must use the minimal amount of reasonable and necessary physical force.

It was determined through interviews that a staff member did push a child, making the child fall and hit their head.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

It was found during the investigation a child sustained injuries as the result of an improper restraint.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

Staff were not aware and accountable of a child's activities when the child was able to obtain a razor and cut themselves seriously enough to where the child required medical attention and had stitches for the injury.

From the state's report. Risk level: High. Cited: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity.

The following report was discussed: This Department investigated an allegation that Staff inappropriately touched youth in care.

From the state's report. Substantiated. Cited: 87072(c)(11).

Both clients who had assaultive incidents with [Staff 1] confirmed the [Staff 1] had assaulted each of them on separate occasions.

From the state's report. Substantiated. Cited: 86172(b)(2). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

On 04/04/2022, the San Jose Children's Residential Program Regional Office received a complaint for Newport Academy Paloma with three allegations: (1) Staff do not provide a safe and healthful environment for residents in care; (2) Inappropriate touching by one residents toward residents; and (3) Inappropriate sexual language used by one resident toward residents.

From the state's report. Substantiated. Cited: 84072(d)(11), 80078(a).

On 06/02/22, Community Care Licensing (CCL) received a complaint alleging client #1 is sexually abusing other clients. [...] The allegation [Child 1] is sexually abusing other clients is substantiated at this time.

From the state's report. Substantiated. Cited: 80078(a). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Confidential interviews reported that [Staff 1] admitted using the word prostitution towards [Child 1] instead of the trauma inform approach Commercial Sexual Exploitation Children (CSEC) during a meeting with County Social Worker.

From the state's report. Substantiated. Cited: 84072(d)(10). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

In plain words: A staff member pushed a child onto a bed and punched the child in the face, leaving a mark and causing pain. Police came to the home after the child texted a friend about another staff member. Our summary of the state's report. The state's own wording follows.

Client #2 eloped from the facility. [...] He had eloped from the facility about 3 times. [...] Staff #1 had pushed him to the bed and punched him in the face a couple months ago. Law Enforcement (LE) responded to the home after he texted a friend about staff #6. [...] Staff #1 stated "you want to kick the wall." Client #1 said "why are you hurting me?" Staff #1 said “you ain't got no money you ain't going to do no Property damage, You ain't kicking no doors and walls. [...] Staff #1 pushed him to the bed and “punched” him in the face once [...] He had a mark on the right side of his face from being punched by staff #1. He was in pain for about 2 days after he was punched by staff #1. [...] Staff #1 "pushed" client #1 onto the bed. [...] There was an allegation a staff hit a client in the jaw. [...] The CPS worker said the allegation was a 40 year old male, who she identified as staff #1, had body slammed client #1.

From the state's report. Deficiency cited, complaint survey, Type A1 violation. Cited: V 366] 27G .0603 Incident Response Requirments V 366 | |. "[...]" marks text left out between sentences.

On March 24, 2022, Community Care Licensing received information alleging that Staff #1 (see LIC811 dated 03/14/2023) pushed minor #2 (see LIC811 dated 03/14/2023) while in care. Confidential interviews with two staff revealed that the minor was pushed by the staff while multiple witnesses were present. [...] Confidential interviews confirm that the staff member #S1 did push the minor in care. [...] Based on interviews and information gathered during the investigation, the preponderance of evidence standard has been met and the Department has determined the allegation that the staff #1 pushed the minor #2 while in care is substantiated.

From the state's report. Substantiated. Cited: 87072(c). "[...]" marks text left out between sentences.

During the course of the investigation it was determined a staff member encouraged children in care to show staff their private parts and requested that the children engage in inappropriate sexual activity.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

A staff member hit a child in care.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

Upon reviewing letters and pictures from a caregiver it was determined that the caregiver has maintained an inappropriate relationship with a child in care.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

Individual #1 was physically assaulted a second time on 9/22/19 and during that assault there was again only one staff member present with the group of individuals.

The provider failed to report a Level II serious incident involving individual #1 which occurred 9/22/19 in which the individual was physically assaulted. [...] After Individual #1 is physically assaulted, the provider suggests, and offers to put into place, a corrective safety protocol. [...] Another Level II serious incident occurred on 9/22/19 in which Individual #1 was physically assaulted a second time and during that assault there was again only one staff member present with the group patients.

From the state's report. Non-compliance, DBHDS investigation. Cited: 12VAC35-105-150. (5) The provider including its employees, contractors, students, and volunteers shall comply with: 5. The provider's own policies. All ...; 12VAC35-105-160. D. (2) The provider shall collect, maintain, and report or make available to the department the following information: 2. Level II and Level .... "[...]" marks text left out between sentences.

Based on confidential interviews by (IB), ([Staff 1]) (see LIC 811 confidential names dated 9-27-22) sexually assaulted ([Child 3]) on three separate occasions, that occurred in a location outside of the facility. Based on the information obtained, there is a preponderance of the evidence to prove that staff had a sexual relationship with a foster child.

From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

A caregiver failed to abide by a child's supervision requirements which resulted in a suicide attempt.

From the state's report. Risk level: High. Cited: 748.685(a)(3) - Caregiver responsibility - being aware of and accountable for each child's on-going activity.

During the investigation it was determined that children were subjected to corporal punishment when staff members pulled them by their arms.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

Children interviewed reported that during restraints it was hard to breathe, or that they could not breathe.

Children also stated that they had witnessed staff perform restraints this way and that they heard the children say that they were being hurt.

From the state's report. Risk level: High. Cited: 748.2605(a)(1) - Personal Restraints Prohibited-Restraints that impair child's breathing by putting pressure on child's torso; 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

Assessment dated 1-6-23 revealed: escalating aggression...3 hospitalizations since 922- 22...attacked his grandparents...attacked school officer. [...] The Maintenance Director reported that he saw Staff #1 yelling, kicking, grabbing Client #3 around the neck and slamming him against the bathroom wall. [...] Phone interview on 1-27-23 with Client #3 revealed: "He (Staff #1) slammed my head into the wall and it hurt me.”

Stated that Staff #1 had grabbed him around his neck and threw him against the wall. [...] Staff #1 grabbed Client #3 by the throat from the front with one hand and slammed him into the wall. This was in Client #3's bathroom and it broke the sheetrock in the bathroom when Staff #1 slammed Client #3's head against the wall.

From the state's report. Deficiency cited, annual and complaint survey. Cited: V 512 Vv 512; V 512} 27D .0304 Client Rights - Harm, Abuse, Neglect. "[...]" marks text left out between sentences.

([Child 1]) was upset with ([Staff 1]) and threatened ([Staff 1]) and started hitting the staff member, which resulted in ([Staff 1]) stabbing ([Child 1]) in the left abdomen. The facility contacted the authorities, and ([Child 1]) was transported to the hospital by ambulance.

From the state's report. Substantiated. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Video camera footage, captured by the facility, showed a staff using her forearm to push a child back into his room, forcing him to comply to directives for quiet, calm down time.

From the state's report. Risk level: High. Cited: 748.2307(1) - Other Prohibited Punishments-any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline/punishment.

Medication was not kept inaccessible other than employees responsible for storing the medication, as a child was able to obtain 6 bottles of medication and ingested an unknown amount of medication, requiring that child to be hospitalized.

From the state's report. Risk level: High. Cited: 748.2101(2) - Medication Storage-Keep medication inaccessible other than to employees responsible for stored medication.

It was also reported that [Staff 1] pushed [Child 1] against the wall during the incident out of anger. Confidential witness statements revealed that [Staff 1] did push [Child 1] against the wall. Based on confidential interviews and records reviewed, the preponderance of evidence standard has been met regarding the allegation that [Staff 1] pushed [Child 1] while in care, therefore the allegation is found to be substantiated.

From the state's report. Substantiated (one of several allegations). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

A caregiver failed to adhere to the child's rights to be free of abuse, neglect, and exploitation as defined in Texas Family Code 261.401.A staff member was found having inappropriate communication and sexual contact with a 17-year-old child in care.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

On 8/31/ 21, CCLD received an allegation reporting that on 08/29/21, [Staff 1] physically restrained [Child 1] causing injuries to [Child 1]'s neck area and possible rib fracture. Licensing Program Analyst (LPA), Regina Martin investigated the complaint allegation and based on information obtained, the preponderance of the evidence standard has been met, the allegation of physical abuse was substantiated.

From the state's report. Substantiated (one of several allegations). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

During the course of the investigation this standard was found to be deficient when a caregiver threatened to physically harm a child in care and pulled him by his hoodie.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

In a video recording, it was heard that staff was threatening to hit and beat children multiple times in a severe manner.

From the state's report. Risk level: High. Cited: 748.1101(b)(4)(A)(ii) - Children's rights-The right to be free from being subjected to or threatened with corporal punishment, including spanking or hitting.

A caregiver engaged in an inappropriate relationship and did not maintain appropriate boundaries when engaging children in care.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

One staff ([Staff 2]) witnessed another staff ([Staff 1]) inappropriately touch a youth in care on two occasions between May and June 2022. [...] Additional interviews corroborated [Staff 1] exhibited inappropriate sexualized behavior toward staff at the facility and at facilities where [Staff 1] was previously employed.

From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Page The Department received a complaint alleging a client was injured during an altercation with staff and staff restrained a minor. [...] In addition to the above information, the investigation revealed staff admitted to law enforcement that a client was restrained during the incident and informed a placing agency investigator the restraint took place on the floor. [...] Record review and confidential interviews corroborated a client sustained an injury to his cheek after being restrained in a prone position.

From the state's report. Substantiated. Cited: 87072(c)(11). "[...]" marks text left out between sentences.

A staff member pushed a child against a wall as a form of discipline.

From the state's report. Risk level: High. Cited: 748.2303(a) - Corporal Punishment-May not use/threaten corporal punishment, such as hitting/spanking, forced exercise, holding physical position, unproductive work..

A caregiver restrained a child by dragging him by his feet while another staff member grabbed his arms immediately after the child had fallen several feet onto a hard floor.

From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

Once on the ground [Staff 1] is on top position restraining [Child 1], [Staff 1] places his left arm around [Child 1]'s neck in a choke hold position and restrains [Child 1] from moving for a few seconds. [...] [Staff 1] releases [Child 1], walks a few steps backwards, [Child 1] gets up and walks towards [Staff 1], [Staff 1] punches [Child 1] in the face with his right hand with a closed fist.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

[Staff 3] contacted non-emergency numbers and Oxnard Police Department. [...] At 6:30pm Oxnard Police Department arrived and detained minor [Child 1]. Oxnard Police Department notified [Staff 2], [Staff 3] that [Child 1] would be placed on a 72-hr hold/5150 at St. John's Regional Medical Center stating he was threatening the staff, children and destroying property. Based on witness, and video footage [Staff 2] conducted inappropriate restrain hold to [Child 1] to prevent from harming himself and others.

From the state's report. Substantiated. "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Staff interviews reveal that staff handled client in a rough manner while performing a one-man restraint causing the client injuries.

From the state's report. Substantiated. Cited: 87072(d)(11).

A tenured campus supervisor was observed on video utilizing inappropriate restraint techniques and physical force against a child resulting in multiple injuries to the child's face, wrist, torso, and back of head.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

During this investigation it was confirmed staff had an inappropriate relationship with a child in care. This same staff was aware of a child self-harming and did not report to hotline or other staff present to ensure the safety of the child.

From the state's report. Risk level: High. Cited: 748.1101(b)(1)(B) - Children's rights-Adhere to the child's rights to be free of abuse, neglect, and exploitation.

Staff member stated during interview they did push victim prior to restraint and did not accept the apology victim offered them. Two children confirmed staff member pushed victim to the floor.

From the state's report. Risk level: High. Cited: 748.2301(b)(2) - Disciplinary Measures-must not be physically or emotionally damaging to the child.

Confidential interviews, documentary evidence of Special Incident Report (SIR) 788640, and LPA review of video footage of the incident revealed that cleint was improperly restrained and placed in a choke hold..

From the state's report. Substantiated.

LPA confirmed through confidential interviews and incident reports that a staff person engaged in intentional physical contact with youth by pushing or hitting youth with a laptop computer. [...] Title 22 deficiencies were cited regarding the physical abuse.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

A staff member was having an inappropriate relationship with a youth in care.

From the state's report. Risk level: Medium High. Cited: 748.507(1) - Employee general responsibilities-Demonstrate competency, prudent judgment, self-control in presence of children and when performing assigned tasks.

On May 17, 2022, Community Care Licensing (CCL) received an allegation lack of supervision resulted in foster child (Child #1) being sexually abused. [...] Confidential interviews provided consistent statements of sexual acts taking place in the resident's rooms at night when staff were busy performing other duties. [...] Based on confidential interviews and record review the allegation lack of supervision resulted in foster child (Child #1) being sexually abused is substantiated.

From the state's report. Substantiated. Cited: 80078(a). "[...]" marks text left out between sentences. The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.

Three clients reported a staff member solicited nude photos from one client who was Absent Without Leave (AWOL) from the facility. [...] In addition to soliciting nude photos, the clients reported the staff member allowed the clients to use the staff member's cell phone to access social media, which went against facility policy. The staff member also visited a client while the client was AWOL, brought the client food, and took the client to the staff member's home.

From the state's report. Substantiated. "[...]" marks text left out between sentences.

After the restraint, the was observed with scratches on her face and bruising on her wrist and was later taken to the doctor for complaints of pain in her chest and arms.

From the state's report. Risk level: High. Cited: 748.2551(c)(1) - EBI Implementation-Caregiver must minimize risk of physical discomfort, harm, or pain to the child.

On page 346 it states, "The restraints must not cause injury to the child." LPA Diaz was able to identify five nail marks on client's right forearm.

From the state's report. Substantiated.

The preponderance of evidence standard has been met, therefore the allegation [Staff 1] pushed [Child 1] is found to be Substantiated.

From the state's report. Substantiated. Cited: 87072(d)(10). The state numbers or abbreviates the people in a report instead of naming them; we spell its codes out in square brackets, such as [Staff 1] for S1 or [Former client 3] for FC #3.