Severe reports

The report indicated that [Resident 3] contacted the Administrator, [Staff 2], and [Staff 2] directed [Staff 3] to take [Resident 1] to the emergency room for a "rape kit." The incident report further indicates that [Resident 2] and [Resident 3] were the alleged perpetrators of the assault. A review of the discharge paperwork from the hospital confirmed that [Resident 1] was evaluated for sexual assault and had contusions. In an interview over the telephone, [Staff 2] originally reported being unaware that there were any allegations of sexual or physical assault. [...] I need to speak to you asap because apparently a staff member sat and watch this happened and laugh... we really need the cameras." In an interview, [Staff 3] reported that [Staff 5] was the overnight behavioral health technician (BHT) and that [Resident 1] reported that [Staff 5] watched the assaults occur and did not intervene.

In an additional interview over the telephone, [Staff 2] reported never stating being unaware that there were any allegations of sexual or physical assault. [Staff 2] reported being aware only of the physical assault and not the sexual assault.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-716.A.7.b. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: b. Share any space, participate in any activity or .... "[...]" 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.

The document stated, “The client, [Resident 1], reported an allegation that staff had physically hit [Resident 1] and caused a mark. [Resident 1] further stated that [Resident 1]intended to present this claim at school. [...] On March 31, 2026, at approximately 6:30 AM, during the morning routine at Mattie’s Care House, LLC, [Resident 1] made a concerning statement indicating [Resident 1's] intent to report an allegation of abuse against staff. [Resident 1] stated that [Resident 1] planned to go to school and report [sic] that staff had hit [Resident 1] and caused a mark. [Resident 1] further expressed that [Resident 1] would create the mark [sic] [Resident 1] in order to support this claim. [...] 7. While on site, the Compliance Officer observed [Staff 1] conduct a phone call to the local police department.

From the state's report. Deficiency cited, complaint. Cited: R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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.

The nurse determined that Urgent Care or ER services were not needed and recommended that a PCP appointment be scheduled for further evaluation. [...] Shorty after, around 1450 the Member got up from [Resident 1's] seat and rushed towards [Resident 1's] peer and physically assaulted peer by throwing a barrage of punches to peer's torso and head.

From the state's report. Deficiency cited, complaint. Cited: R9-10-703.C.2.a. Administration C. An administrator shall ensure that: 2. Policies and procedures for behavioral health services and physical health services .... "[...]" 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 1] later reported BHTs provide medication administration as BHTs punch out the medications from the pharmacy-provided multi-dose packaging, place them into a cup, and give to residents. [...] The MAR stated “… Count off by 2 … 5/22/25 7:58 Chlorpromazine 25 given two to equal 50mg gave, nd [sic] two 25 mg at bedtime … 5/23/25 8:00am Chlorpromazine 25 given 50mg wrong dosage given.” 16. [...] In an interview, [Staff 1] stated the medication errors were “staff errors.” 23.

From the state's report. Deficiency cited, complaint. Cited: R9-10-718.B.3.a-b. Medication Services B. If a behavioral health residential facility provides medication administration, an administrator shall ensure that .... "[...]" 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.

In plain words: A staff member and a child fought after the child struck the staff member. The staff member repeatedly slapped, kicked, and punched the child, leaving scratches and a welt on the child's face. Our summary of the state's report. The state's own wording follows.

The report stated, -"The nature and extent of the adult's vulnerability [in the alleged or suspected abuse, neglect or exploitation]: Suspected child abuse, consisting of staff slapped, kicked and punched client." -"The nature and extent of the adult's child injuries or physical neglect or of the exploitation of the adult's child property [include changes to the resident's physical, cognitive, functional, or emotional condition]: Client has scratches on arms and a welt mark across [Resident 1]'s face. [...] Staff then challenged the client, at which point the client lunged towards staff and struck [Staff 5] in the head. Staff raised [their], slapped the client and began punching [Resident 1] with a closed fist. [...] Staff eventually stopped; however, the client continued using profanity, kicked the staff, and pulled [Staff 5's] hair. Staff then became more aggressive by grabbing and hitting the client again.

[Staff 5] slaps [Resident 1] eight times and kicks them once (15:16:39-15:16:45).

[Staff 5] pushes [Resident 1], grabs and holds their arm, slaps them twice (15:14:45 to 15:14:48).

From the state's report. Deficiency cited, complaint and initial monitoring. Cited: R9-10-711.B.1. Resident Rights B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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.

In plain words: Records showed residents earned money for cleaning. A child reported hearing rumors about a staff member and another child having a sexual relationship. An incident report noted a child wrapped a fan cord around their neck while staff were busy, leading to a restraint. During that restraint, a child reported a staff member twisted their wrist and forced them to the ground. Our summary of the state's report. The state's own wording follows.

[Resident 5]'s and [Resident 10]'s pages documented that on May 25, 2025 and June 7, 2025, [Resident 5] and [Resident 10] earned $20 per day each for "cleaning apartment," and $10 each on June 3, 2025 for "cleaning feet." 7.In an interview, [Resident 3] stated [Resident 5] is [Staff 1]'s "number one worker," and that [Resident 3] has heard rumors from multiple people regarding [Resident 5] and [Staff 1] being in a sexual relationship. [...] 9.In an interview, [Resident 5] reported other residents have made comments to [Resident 5] about [Resident 5] and [Staff 1] being in a sexual relationship.

A review of [Resident 4]'s medical record revealed a document titled, "Incident Report Form," dated May 25, 2025, which stated, "..There was a situation going on that had staff a bit pre-occupied and peer...went to talk to [Resident 4] and found [Resident 4] with a standing fan cord wrapped around [Resident 4's] neck. [Peer] yelled for staff...[Resident 4's] peer...came out of the room carrying the standing fan...[Resident 2] was sitting on the bed and [Staff 7] moved into escort [Resident 4]...[Resident 4] was put into a PCS restraint to escort [Resident 4] down the hall..." 7. [...] During this restraint [Resident 2] reported staff twisted [Resident 2]'s wrist and put [Resident 2] down to the ground, stating "it hurt." [Resident 2] also stated staff will use their hands or knee to hold the residents down on the floor "like police grabbing you." 10.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.7.a. Behavioral Health Services A. An administrator shall ensure that: 7. A resident does not: a. Use or have access to any materials, furnishings ...; R9-10-711.B.2.i. Resident Rights B. An administrator shall ensure that: 2. A resident is not subjected to: i. Restraint;. "[...]" 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.

In plain words: A youth program supervisor stated a child in the program reported a staff member pushed and hit the child. Our summary of the state's report. The state's own wording follows.

3. A review of [Resident 1] ' s medical record revealed a document titled "Florence Crittenton Internal Investigation Report." The report included a "Summary Timeline of Events" which stated, "Tuesday, September 3, 2024, On Sunday, September 1st, 2024, Youth Program Supervisor [NAME] notified [Staff 5], [Resident 1 ' s] grandmother called the Campus Lead ' s phone, stating, "[Resident 1] reported staff pushed [Resident 1] and hit [Resident 1].

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. 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.

At approximately 0:12 seconds in, [Resident 1] tried to exit the room again and [Staff 1] forcefully extended [Staff 1]'s and pushed [Resident 1] towards the middle of the room.

From the state's report. Deficiency cited, complaint. Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; B. An administrator shall ensure that: 2. A resident is not subjected to: a. Abuse;. 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 2] stopped walking and stiffened his body, mostly [Staff 2]'s arm, stuck out his elbow and [Staff 2]'s elbow hit [Resident 1].

"[Staff 2] stopped walking and stiffened [Staff 2's] body, mostly [Staff 2's] arm, stuck out [Staff 2's] elbow and [Staff 2's] elbow hit [Resident 1].

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: I. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises ...; B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. 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.

The client was transported by EMS to the hospital; Individual's Condition Before & After the Incident: Physically fine before the incident but became upset during the incident. [Resident 1] was crying and in pain after the incident; Description of any Medical Services Received: EMS transported [Resident 1] to the hospital where [Resident 1] was treated for first degree burns to [Resident 1's] chest." 2. [...] 3. In an interview, [Staff 1] and [Staff 2] reported the first peer who threw water on [Resident 1] used hot water and the second peer used cold water, after [Staff 1] and [Staff 2] investigated the incident. [Staff 1] and [Staff 2] reported removing the peer who threw hot water from the facility and relocating the peer who threw cold water.

From the state's report. Deficiency cited, complaint. Cited: B. An administrator shall ensure that: 1. A resident is treated with dignity, respect, and consideration;. "[...]" 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.