Complaint Investigation Report

Allegation: Licensee did not ensure that minimum staffing requirements were met.

It is alleged that Licensee did not ensure that minimum staffing requirements were met. Regarding this allegation it is reported that on 10/01/25 North Los Angeles Regional Center (NLARC) conducted an unannounced visit and discovered that the facility failed to meet the direct care staffing hours requirement as outlined in their approved program design of 408 staffing hours between 9/28/25 and 10/04/25, violating the terms of the client’s admission agreements. LPA interviewed Administrator who denied the allegation stating that there is ample staff to cover all hours as described in the program design. Administrator states that there are three (3) clients and that none of them require additional staff such as one on one (1:1) at the facility. Administrator also stated that even when there are no clients due to them attending day program, there is still a staff member in the facility doing administrative duties, further emphasizing that there is always enough staff available. Administrator revealed that in the program design there is no specification of minimum or maximum staff to client ratio or a specific number of hours of coverage, however, it does state that there will be direct care staffing levels that exceed the requirements of a level 4I facility. Per the Administrator a level 4I facility requires approximately 318 hours of staffing and the facility at the time of the inspection was providing 327 hours and above, currently the facility is providing 408 hours of staffing, proving that there is no violation of the client’s admission agreements or the program design. Further, the Administrator states that the program design that was approved by NLARC has a “sample” 24-hour schedule and as a sample it was subject to change once the clients were admitted and since has provided the hours that exceed a level 4I as stated in the program design. Administrator states that for the last two (2) years, this has been the practice of the facility, providing more than the approximate minimum 318 staffing hours for a level 4I and that both Title 17 for a Specialized Home and Title 22 do not have specific staffing ratio or hour requirements. Interview with three (3) staff revealed that there is always enough staff to cover all shifts with approximately two (2) staff on shift and sometimes a third staff member during the overlap time where staff give report of any updates regarding the facility and/or clients. Interview with Client #1 (C1) revealed that there are always staff around and there is no lack of care and supervision.