Complaint Investigation Report

Allegation: Staff inappropriately relocated a resident

The allegation alleges a Client was relocated to another facility without the proper paperwork.

During record review, LPA received and reviewed Client C1’s Admission Agreement dated 06/15/2025 for the facility they were transferred to. The Admission Agreement is signed by Client C1, C1’s conservator, Trust Management Services, the Licensee, and Regional Center Representative. LPA received and reviewed Client C1’s 2025 Annual Progress Report dated 04/30/2025, that states as C1 “gets older and transitions into a more sedentary lifestyle, it is getting harder for C1 to keep up with the other roommates.” Additionally, it states “discussions have started to explore and consider a more suitable environment to ensure C1 continues to have the support C1 will need in the future.” LPA received and reviewed Client C1’ Individual Person-Centered Plan dated 06/20/2024 that indicates C1 may need some prompting and directions while grooming, showering and completing tasks.

During interviews with Staff S1-S4, were asked if any clients were recently transferred to another facility due to requiring a higher level of care, four (4) out of four (4) stated yes, Client C1 recently transitioned to another home due to requiring a higher level of care. Additionally, staff S1-S4, were asked what the process was prior to C1 moving, four (4) out of four (4) stated there was an assessment, medical appointments, meetings with the conservator, and regional center before the decision was made.

LPA contacted Client C1’s service coordinator from Harbor Regional Center, who stated there were meetings, assessments, and discussions with the facility, regional center, and C1’s family regarding C1 being transferred to a facility that can provide a higher level of care.

During an interview with Client C1, was asked how they like the new facility they are residing in, C1 stated they like it. Additionally, C1 was asked if they chose to move there, they stated yes, they went there because they like it.

Allegation: Staff falsified staff documents

The allegation alleges that staff are asked to sign documents indicating they have received training when they have not.

During the facility tour, LPA observed posted on the board is the Star House #1 Training Schedule for Year: 2025. The topics and the months the training will be provided was listed.

During record review, LPA received and reviewed training logs for staff for in-services conducted for 2025. The following are in-services that were provided to the staff: Home and Community Based Services on

01/04/2025 and 01/10/2025, Health Insurance Portability and Accountability Act (HIPPA) on 01/04/2025, A Thorough Understanding of the 7 Rights of Medication Administration on 01/28/2025, Medication