Complaint Investigation Report

During interviews with the clients, none of them corroborated the allegation. One of the clients interviewed stated that they have been getting all the medications that they require and that they have no issues with obtaining them. Another client interviewed stated that everything is okay with their medications. During interviews with the staff, four (4) out of four (4) corroborated the allegation. One staff interviewed stated that they were aware that there were errors in distributing the medications to C4. Another staff interviewed also stated that they were aware of the medication error and that the PRN medication for C3 had expired, and that they had ordered a refill of a medication. During review of the medications and MARs for the clients, LPA observed that C4 was given a medication which according to the doctor's order should only be given when their blood pressure is higher than 140/90, however on on 6/4/2025 it was given when their reading was 139/86. LPA also observed C3's PRN medication will need to be ordered, and observed evidence from staff that it has been.

In regards to the allegation " Licensee did not ensure that all direct services to clients requiring specialized skills are performed by personnel who are qualified," it is alleged that some of the staff in the facility did not complete required training to be qualified to provide direct services to clients including Direct Support Staff 2 (DSP2) training. During interviews with clients, none of them corroborated the allegation. All of the clients interviewed stated that the staff are all helpful and assist them with all their needs. During interviews with the staff, four (4) out of four (4) corroborated the allegation. S3 stated that she had been working at the facility for three (3) years, however she needs to obtain her DSP2 training certificate which is required after working as a DSP after working at a facility for two (2) years. Another staff interviewed stated that they were aware that S3 required their DSP2 training, and possibly S5 as well. During record review of the staff, LPA determined that S3 will need their DSP2 training, and S5 as well because their DSP2 training was not found in their file.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED . California Code of Regulations Title 22, Division 6, Chapter 1 and Chapter 6 is being cited on the attached LIC9099D pages.

Exit interview was held and a copy of the report along with the appeal rights were provided and will be emailed to the administrator.