Complaint Investigation Report

Interviews with staff S1, S2 and S3 revealed client (C1) sometimes want to be in his room. C1 comes downstairs and sits on couch, watching television with the other clients. Staff encourages the clients to hang out with each other after attending the day program. C1 sometimes hangs out with others and sometimes he does not. C1 would go in his room when the other clients would get noisy.

Staff did not provide adequate supervision to manage resident's behaviors.

Interview with W1 revealed W1 working with Regional Center of East Bay (RCEB) to get C1 a one-to-one staff 1:1 ratio. Record review revealed C1 does not have a 1:1, record review also revealed facility staff is sufficient in numbers to support the care needs of the clients in care.

Staff did not assist resident with toileting.

Interviews with S1, S2, and S3 revealed, C1 goes to the restroom by himself without assistance. C1 will urinate on carpet next to bed in the middle of nights and early mornings. S1 and C1’s mother agreed to place a rubber mat next to bed to prevent carpet from being destroyed.