Complaint Investigation Report

To stop C1’s self-injuring and aggressive act, the Administrator apply temporary hold on C1 until C1 calmed down. On 04/23/2021 LPA Margaryan requested C1’s facility file and no records were provided.

On 04/25/2021 at 2:00pm, LPA Margaryan spoke with other witnesses involved in C1’s care and supervision. Interviews revealed that although C1 has aggressive behavior, the use of manual restrains are prohibited to control C1’s behavior. A review of incident report submitted to the Licensing office on 01/26/2021 verified the information received from the Administrator. The information revealed during this investigation verified the allegation. Therefore, the allegation is substantiated at this time.

- Facility did not have sufficient staff to meet clients' needs.

It was alleged that C1 requires one to one supervision and the facility had only 1 staff for 3 clients.

To investigate the allegation, on 04/25/2021 at 2:30pm, LPA spoke with the Administrator. Interviews revealed that the Administrator had knowledge that C1 requires close supervision. However, she was unable to bring additional staff to supervise C1 due to staffing shortage.

On 04/25/2021 at 3:00pm LPA Margaryan requested staffing schedule and the Administrator informed that LPA that she was the only staff at the facility. The information available during this investigation, verifies the allegation. Therefore, the allegation is substantiated at this time.

- Clients' were not adequately supervised.

It was reported that the facility clients were left in the car without staff supervision.

On 04/25/2021 at 2:30pm, LPA spoke with the Administrator and she admitted and verified that she left three (3) clients in the car while she went to get the gas and the food previously ordered for the clients. The information revealed from interviews verifies the allegation. Therefore, the allegation is substantiated at this time. (continued on LIC 9099-C)