Complaint Investigation Report

The investigation revealed the following: Allegation: Licensee did not ensure facility was operating within ratio. It was alleged that the day program was out of ratio. On 02/02/26 3 staff were at the facility with 15 clients.

LPA interviewed Program Director and 4 staff. Interviewed Program Director indicated that the day program staff to client ratio is 1 to 3 and acknowledged that there were some days that facility was short staffed and the staff to client ratio was over due to resignations, vacation and unexpected call offs. The Program Director stated some staff called out at the last minute. Program Director stated they tried to find the coverage from other locations which doesn't always work out. Also the Program Director stated facility is actively trying to hire additional staff to operate within Regional Centers required 1:3 ratio . Program Director confirmed that there were times when the client to staff ratios were not met. All staff interviewed confirmed the above allegation and stated that although their ratio should be 1:3 (one staff to 3 participants) they often operate with a 1:4 or 1:5 ratio as there are staff call offs. They mentioned that last week in particular there weren't enough staff at the program. Interviewed S2 and S3 stated on 02/02/26 and on 02/06/26 there were 3 staff on the floor with 15 clients. LPA was able to interview one client; however, the others did not appear to have the cognitive ability to answer questions. Interviewed C1 stated not knowing if the facility is short staffed.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Exit interview held, and a copy of this report and appeal rights provided to Assistant Program Director.