Severe reports

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.

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.

The document stated, "...Staff informed...[Resident 1] attempted suicide by choking [Resident 1's] self with a shirt to the point [Resident 1] was unconscious [sic] staff immediately called 911. Staff explained that the incident occurred after [Resident 1's] peer was being moved to CRC...[Resident 1] became upset leading [Resident 1] to thoughts about when [Resident 1] would be going home...[Resident 1] went to [Resident 1's] room and shortly after [Resident 1] was found on the floor unconscious with a shirt tight around [Resident 1's] neck. [Police Department] was already on site because of another incident...[Resident 1] was transported to [hospital]...[Resident 1] moved to a higher level of care for now..." 2. [...] The document stated, "...Member attempted to self-harm using a bed sheet to choke [Resident 1's] self. [...] [Staff 7] reported [Staff 1] immediately called 911, removed the shirt, and checked to see if [Resident 1] was breathing. [Staff 7] reported EMS took [Resident 1] to [hospital] and [Resident 1] was transferred to a higher level of care.

From the state's report. Deficiency cited, complaint. Cited: R9-10-716.A.2.b. Behavioral Health Services A. An administrator shall ensure that: 2. If a behavioral health residential facility is licensed to provide .... "[...]" 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: The state found that the administrator failed to keep the required log of unauthorized absences for at least 12 months. The complaint stated that a resident ran away after a fight and later passed away, and that other residents also ran away after fights. Our summary of the state's report. The state's own wording follows.

Based on documentation review, record review, and interview, the administrator failed to maintain a log of unauthorized absences for at least 12 months after the date of a resident's absence to include the name of a resident absent without authorization, name of the individual to whom the report required in subsection (K)(7) was submitted, and the date of the report. [...] The complaint alleged a resident (later identified as [Resident 2]) had an unauthorized absence and later passed away. [...] The email stated "[Resident 2] and two other [residents] ganged up fought another [resident] and afterwards they ran away." 7. [...] The text message stated "[Resident 3] fought another [resident] then ran away." 8. [...] The text message stated "[Resident 4] ran away at 8:00 am [sic] after fighting another resident." 9. The Compliance Officer requested to review the facility's written log of unauthorized absences.

From the state's report. Deficiency cited, complaint and compliance (annual). Cited: K. An administrator shall: 8. Maintain a written log of unauthorized absences for at least 12 months after the date of a resident's absence that includes the .... "[...]" 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: An administrator failed to notify the state in writing within one working day about a resident's death from a reported drug overdose. Our summary of the state's report. The state's own wording follows.

Based on documentation review and interview, the administrator failed to provide written notification to the Department of a resident's death, if the resident's death was required to be reported according to A.R.S. § 11-593, within one working day after the resident's death. [...] The e-mail from O1 was dated September 27, 2023 and stated "I received a call from Durango Detention and they informed me a medical examiner [O2] called them and they identified a youth that has an ankle monitor that has been deceased...I asked if [O3] knows what happen and [O3] stated early in the morning, a witness stated [Resident 1] was seen smoking a unknown substance at a QT off [street name] and [Resident 1] was taken to the emergency room where [Resident 1] died of a drug overdose..." 3. A review of Department documentation revealed the administrator failed to provide written notification to the Department of [Resident 1]'s death.

From the state's report. Deficiency cited, complaint. Cited: G. An administrator shall provide written notification to the Department of a resident's: 1. Death, if the resident's death is required to be reported .... "[...]" 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.