Complaint Investigation Report

***This report serves as an amendment and supersedes the original complaint investigation report created on 04/20/22. The findings remain as Unsubstantiated. ***

On 04/20/22, LPA Gail Johnson and Licensing Program Manager (LPM) Ulysses Coronel conducted a subsequent visit at the facility, interviewed administrator, Staff#1 (S1), reviewed client#1’s files, toured the facility, and delivered finding.

On 03/24/23, LPA Tao conducted another subsequent visit. During the visit, LPA obtained copies of staff and client rosters, interviewed administrator, reviewed clients’ files, conducted a facility tour, and delivered findings.

The investigation consisted of resident interviews, staff interviews, residents’ files review, and facility tour.

The investigation revealed the following. Regarding the allegation “staff does not provide resident adequate care and supervision,” it is alleged that the facility is not preventing C1 from absent without leave (AWOL). On 02/13/2020, LPA Tao interviewed thirteen (13) clients and three (3) staff. LPA Tao attempted to interview Client #1 (C1) for multiple times at different time and on different days. All attempts failed. Seven (7) out of thirteen (13) clients interviewed could not corroborate the allegation. Client#3 (C3) stated “It’s alright, it’s better than some other board and care”. One (1) out of thirteen clients agreed with the allegation stating “not happy with the facility and management, but it is better than living on the street. Four (4) out of thirteen (13) clients denied to be interviewed.

All three (3) staff interviewed denied the allegation. On 4/20/2022, LPA Gail Johnson conducted record reviews indicated that the facility’s in-house psychiatrist was in contact with C1 from 12/03/2014 to 02/26/2020 and needs and services plan were conducted on an annual basis. The most recent needs and services plan was conducted on 05/02/2019. On 04/20/2022, Administrator Garcia stated “We are not a locked facility, clients have the right to come and go as they please. During admission we advise the clients to use the sign-out sheet, we ask them to let us know when they plan to come back and where they are going. We explain to them, that if they are AWOL within 24 hours a missing person police report will be made. We don’t want to kick clients out in the streets. C1 went AWOL on 06/01/2020 and never returned".