Complaint Investigation Report

LPAs interviewed 3 of 7 clients. All clients interviewed state that they are able to do their laundry and none has had any issue with laundry. In case the laundry room door is closed, they can ask one of the staff to open for them to wash their clothes.

During the annual inspection conducted on 1/14/2025 and 10-day visit on 1/29/2025. LPAs observed medications were stored in a cabinet next to one of the counseling rooms. S1, who is responsible in passing medications was observed by LPAs unlocking/locking the cabinet door. During the visit, LPAs also reviewed medications and Medication Administration Record (MAR).

On said annual inspection, LPAs reviewed 7 of 7 client files and 3 staff files. LPAs did not observe any unusual concerns with the files reviewed. On 3/3/2025, LPAs reviewed proof of staff training for the months of December 2024, January and February 2025. Trainings were conducted with staff on topics such as Cultural Humility, Communication with Clients/Colleagues, Managing and De-escalating Aggressive Behavior, Understanding, Recognizing and Helping Clients who self-harm, etc. Trainings were conducted by Janet Natale, a Licensed Marriage Family Therapist (LMFT).

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.