Complaint Investigation Report

LPA interviewed five staff members regarding the complaint and four of the five staff members stated had witnessed physical altercations between the two residents at the facility. Staff members stated there were times when staff were unable to redirect both residents and injuries occurred as a result of the altercations. LPA Spaeth received eight incident reports since January, 2020 which stated both R1 and R2 had engaged in physical altercations.

On January 10, 2020, LPA Kelly Dulek conducted a case management visit during a subsequent complaint visit for complaint control #31-AS-20191212170618 to take photos of proposed changes to facility space. LPA met with facility administrator Linda Hughes. Administrator Shreda Powell had contacted LPA Dulek and informed LPA of the intent to change the current staff office space into a functional client bedroom. Ms. Powell e-mailed a new facility sketch and LPA Dulek provided Ms. Powell with an LIC 9054 Local Fire Inspection Authority form. LPA toured the facility at 4:15 PM. Ms. Hughes informed LPA that the water heater will be relocated to outside the building as required prior to using the space as a client bedroom.

On 5/18/2020, LPA Spaeth conducted a case management – Incident visit in response to several incident reports that were sent to Community Care Licensing Division (CCLD). Administrator, Shreda Powell had stated staff were implementing activities to re-direct R1 and R2. On October 15, 2020, LPA Spaeth spoke to Shreda Powell (Administrator) at 10:00 am stating the purpose of the call was to discuss the number of incident reports describing physical altercations between R1 and R2. Administrator Powell stated there were issues with R1 and R2 because both residents share a room with each other. Administrator stated to LPA Spaeth that Administrator was planning to convert the office into a resident room. However, the office has not been converted into a resident room. Based upon staff interviews and the incident reports which state R1 and R2 obtained personal injuries while living at the facility, this complaint is substantiated at this time.

Pursuant to Title 22 California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report along with the appeal rights provided to licensee via email.