Complaint Investigation Report

Interviews were also held with Staff# 2 (S2), attempted interviews with Clients# 3-4 (C3-C4), and a telephonic interview was held with C1’s previous placement agency, Service Coordinator (SC). LPA was unable to interview C1 due to C1 no longer residing at the facility, and unable to interview C2 due to C2 being out in the community during the visit. A tour of the physical plant was also conducted with assistance of Administrator Peter Munzon, with special focus on C1’s old bedroom.

The investigation revealed the following:

Regarding allegation: Facility staff mismanaged a resident's medication.

It is alleged that when C1 went home for the weekend in July of 2021, C1's family received a call from the facility asking to check C1's medication bag, only to find C2's evening medication in C1's bag. Per interviews conducted with staff, (2) of (2) staff denied the allegations. S1 stated that the placement agency conducted their own investigation and did not find any discrepancies or issues with any of the client’s medications at the facility. Per interview with SC, the regional center did in-fact investigate this allegation and was found unsubstantiated. (2) of (2) clients could not corroborate the allegation due to limited communication. This allegation is Unsubstantiated.

Regarding allegation: Facility spent residents P&I funds inappropriately.

It is alleged that C1’s Personal and Incidental (P&I) funds were spent daily on Domino’s Pizza, for the months of July and August 2021. After review of C1’s P&I ledger and receipts, it was noted that funds were spent on Domino’s Pizza about two to three times per month for the entire year of 2021. P&I funds were also found to have been spent on other food purchases, clothing, an iPad, shoes, and a vacation fund. Per interviews conducted, (2) of (2) staff stated that S1 handles P&I for the clients and is only spent on what they want and need. Per S1 and SC, the vacation fund was approved by the placement agency. However, C1’s family did not approve of the vacation fund and the money was refunded to C1. S1 and SC also stated that the placement agency investigated this allegation and after review of the ledger and receipts, the allegation was unsubstantiated. (2) of (2) clients could not corroborate the allegation. This allegation is unsubstantiated.

Regarding allegation: Facility did not provide nutritious meals for resident.

It is alleged that due to C1 eating Domino’s Pizza daily for two months, which is not nutritious, C1 has no developed and ulcer, a hernia, and several cavities. (2) of (2) staff interviewed stated that nutritious meals are cooked and provided to clients daily. S1 stated to be unaware of C1 developing a hernia or ulcer during C1’s stay at the facility. S1 and C1’s family would regularly take C1 to doctor appointments. However, when C1’s family took C1 to the doctor, S1 was not provided information regarding the outcome of the appointments.