Complaint Investigation Report

(Cont. from LIC9099) LPA reviewed and obtained copies of the client roster, Personnel Report (LIC 500), staff schedule around the time frame the initial complaint was made, Client #1’s (C1) Physician’s Report, and C1’s Individual Program Plan (IPP).

Allegation: Facility staff did not prevent resident from gaining access to hazardous items that should be stored inaccessible. It was alleged a staff allowed C1 to access staff keys and unlock a closet containing hazardous items. To investigate the allegation LPA Rios interviewed two (2) out of four (4) clients, four (4) staff and the administrator. LPA Rios also conducted a physical plant tour. During today's visit, LPA observed that both the closet designated for hygiene products and the cabinet under the sink storing cleaning supplies and poisons were locked.

During LPA's interview with the administrator, it was confirmed that hazardous items such as, Cockroach/Spider Killer spray and Clorox Urine Remover, were stored in a closet designated for hygiene products only. The administrator stated that staff should not have placed such items in that particular closet. However, the closet was locked, and the administrator believes a staff member may have intentionally provided the keys to C1 and taken the picture to make the facility look out of compliance. Interviews with two (2) out of four (4) staff members corroborated witnessing Staff #1 (S1) provide the facility keys to C1, to obtain items from the hallway closet. Additionally, one (1) staff member reported observing S1 give the keys to C1 without close supervision, noting that S1 was watching from a distance as C1 accessed the closet. During LPA's interview with C1, C1 denied the allegation. During LPA’s interview with Client #4 (C4), C4 stated that they had seen C1 with the facility keys. However, C4 was unable to say when they saw this occur, which staff had provided the keys, or if staff were providing close supervision at the time.

LPA Rios reviewed photos submitted to Community Care Licensing (CCL), which show C1 in possession of the facility keys. The keys were identified by the distinct lanyard attached to them. In the photos, C1 is seen opening the closet located in the hallway leading to clients' bedrooms, and in another picture the closet door is visibly wide open. On 08/26/2025 a credible witness conducted a visit to this facility and inspected the closet C1 reportedly accessed and discovered hazardous materials inside, including one can of cockroach killer, three cans of Clorox Urine Remover, and various hygiene products. Based on the credible witness and LPA's interview this allegation is Substantiated at this time.

Deficiency cited. Exit interview conducted. Appeal Rights provided. Copy of report provided.