Complaint Investigation Report

Allegation: Staff does not allow clients entry to the facility at all times.

It is alleged that The Licensee requires all clients to leave the facility from 8:30 a.m. to 1:30 p.m., Monday through Friday. On 02/25/26 from 11:00 am- 12pm conducted Interview with (S1) regarding the allegation above. S1 denied the allegation above and reported that it is not mandatory for clients to be out of the facility, however clients enjoy going to their day programs. On 02/25/26 and 03/19/26 LPA conducted interviews with C1-C8 regarding the allegation above. 3 of the 8 clients interviewed denied the allegation above, 2 of the 8 clients interviewed confirmed the allegation above and reported that clients cannot be home as Licensee has errands to run, 3 of the 8 clients interviewed reported having no knowledge of the allegation above as they do not miss programming. On 02/26/26 LPA conducted a telephone interview with S2 regarding the allegation above, S2 denied the allegation above.

Allegation: Staff does not allow visitors access to the facility during business hours

It is alleged that the Licensee does not allow visitors at the facility from 8:30 a.m. to 1:30 p.m., Monday through Friday. On 02/25/26 from 11:00 am- 12pm conducted Interview with (S1) regarding the allegation above. S1 denied the allegation above and reported that visitors can visit the facility whenever they want. Per S1, all clients signed and obtained a copy of the house rules upon admission. Additionally, S1 reports that S1 sent Licensing Program Manager (LPM) Cifuentes an updated rules/policy but I have not heard back to know if they are approved or not. On 02/25/26 and 03/19/26 LPA conducted interviews with C1-C8 regarding the allegation above. 7 of the 8 clients interviewed denied the above allegation. 1 of the 8 clients interviewed confirmed the above allegation. On 02/26/26 LPA conducted a telephone interview with S2 regarding the allegation above, S2 denied the allegation above and reported that visitors are allowed at the facility until 10 pm daily. On 03/03/26 LPA conducted a review of facility rules, per facility rules the curfew for the facility is 10pm. On 03/03/25 LPA conducted a review of the admission agreement for C1-C3. Per admission policy, the visiting policy is as follows: Monday-Friday afternoons 1pm-10pm after clients return from programming and Saturday-Sunday all day.

Allegation: Staff does not ensure ratio requirements are followed.

It is alleged that the Licensee does not have enough staff to care for all clients in care. On 02/25/26 from 11:00 am- 12pm conducted Interview with (S1) regarding the allegation above. S1 denied the allegation above and reported there are a total of 4 staff employed including self (S1). Additionally, S1 reported that there are no clients at the facility who require constant nor 1 to 1 supervision. On 02/25/26 and 03/19/26 LPA conducted interviews with C1-C8 regarding the allegation above. 8 of the 8 clients interviewed denied the allegation above and reported there are 2 staff at the facility each day. On 02/26/26 LPA conducted a telephone interview with S2 regarding the allegation above, S2 denied the allegation above. Per S2, there are 2 staff at the facility daily, which are the Licensee in the morning and S2 at night. S2 continued to report there are no clients in care that require constant nor 1 to 1 supervision. On 03/03/26 LPA conducted a review of the employee roster, per roster the Licensee works from 7am-7pm 6 to 7 days a week, S2 works from 7pm- 7am 5 days a