Complaint Investigation Report

Allegation: Staff did not update needs and services plan as needed.

The complaint alleges that facility staff failed to update (C#1)’s Appraisal/Needs and Services Plan following a reported mental health episode.

On November 4, 2025, at approximately 2:00 PM, during the records review, LPA Iniguez examined (C#1)'s copy of the Appraisal/Needs and Services Plan (LIC 624) dated August 14, 2025. LPA Iniguez noted that this is the only plan on file for (C#1) and that there is no updated version following the changes in (C#1)'s mental condition.

On 11/4/2025, at approximately 10:30 am during an interview with the program director (A#1), she stated that (C#1) needs and services plan has not been updated since they were admitted on 8/12/25 and the person that updates the plan is the therapist.

On November 4, 2025, at approximately 11:30 am, during an interview with Client #1 (C#1), they reported that the facility staff did not discuss their needs and services plan with them and that it had not been updated following their recent events. (C#1) also mentioned that their current plan does not adequately reflect their mental health or emotional well-being needs.

On 11/4/2025, at approximately 11:00 am, during an interview with facility staff (S#1-S#4), (4) out of (4) stated that they were unaware of when (C#1)’s Appraisal/Needs and Services Plan was last updated. However, (4) out of (4) facility staff stated that (C#1)’s current Appraisal/Needs and Services Plan reflects their mental and physical needs.