Complaint Investigation Report

On the allegation, facility is operating out of ratio, it is the concern of the Reporting Party (RP) that facility was operating out of ratio as Client # 2 (C2) who requires one (1) to one (1) supervision was observed to not be receiving one (1) to one (1) supervision on 09/24/2024. To investigate this complaint, LPA conducted in person interviews with the Administrator, Two (2) Staff between 9:45 am – 11:00 am. LPA also obtained pertinent documents to the investigation and reviewed facility records.

Interviews with two (2) staff revealed that both Staff 1 (S1) and Staff 2 (S2) were scheduled and present on 09/24/2024. Staff noted that they originally had three (3) staff scheduled but Staff 3 (S3) had called out due to a family emergency leaving the facility out of ratio. Staff stated they typically have three (3) staff scheduled. One (1) Lead staff /Nurse on the floor, one (1) staff as a one (1) to one (1), and one (1) Direct Support Professional. Lead staff and Administrator attempted to find coverage, however unsuccessful. The staff remained as one (1) Lead staff / Nurse on the floor, one (1) staff as a one (1) to one (1). S1 required assistance moving Client 1 (C1) from bed to chair. S2 assisted S1 in moving the client. At this time, the facility was out of ration leaving Client 2 (C2), who requires a one (1) to one (1) alone to assist S1. Staff stated that policy requires two (2) staff to transfer clients from bed to chair or from chair to bed. Interview with Administrator and file review support that the facility was out of ratio on 09/24/2024.

Based on information obtained, interviews with staff and a credible witness, the allegation, facility is operating out of ratio are deemed Substantiated at this time.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8 and California Health and Safety Code the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.