Complaint Investigation Report

On 09/11/23, LPA Maldonado obtained a copy of the staff schedule/client roster, and a copy of the documents initially requested by LPA Long, due to LPA Maldonado not being provided with them prior to the visit. 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.

On 9/26/23, LPA Maldonado conducted telephonic interviews with C1 and C2 at their respective programs.

The investigation revealed the following:

Regarding allegation: Resident's mattress was not placed appropriately.

It is alleged that during a visit at the facility on 08/04/21, C1’s family noted that C1’s bed did not feel right and found the spring side of the mattress to be on the up-side. S1 stated C1’s family brought this to their attention and S1 noted that staff were cleaning the mattress and accidentally left it on the wrong side but corrected it immediately. Moreover, S1 decided to purchase a new mattress for C1, but was unable to use it due to C1 moving out of the facility following the complaint. During the tour of the facility conducted during the visit on 9/11/23, LPA Maldonado inspected C1’s old bedroom and observed the new mattress still in the plastic wrap, placed on top of C1’s old bed. LPA also observed all client rooms to be fully furnished with all the required furniture. S2 stated to not have been at the facility when the incident occurred. However, S2 was made aware of it and stated that S1 purchased a new bed altogether, for C1. But, C1 left before the new bed was delivered. (4) of (4) clients interviewed could not corroborate the allegation. C1 stated to have liked C1's room while living at the facility, but could not provide details or recall issues with C1's bed mattress being on the up-side.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is Substantiated.

Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with DSP, Wilfreda Langa, and a copy of the report and appeal rights were provided.