Complaint Investigation Report

Allegation: Facility is in disrepair. The complaint alleges that on 12/17/2024 a bedroom window screen was observed bent and the glass in the bathroom vent was broken. Administrator stated daughter's kids room window screen was in disrepair and a bathroom vent glass part was missing. All four (4) residents were interviewed, none reported knowledge of dis-repairs. On 1/10/2025, LPA confirmed the aforementioned disrepair of window screen and missing bathroom vent. Pictures were taken. Therefore, there is sufficient evidence to corroborate the allegation.

Allegation: Facility failed to update plan of operation. It is alleged Licensee did not update the facility plan of operation i.e., surveillance cameras were installed in the exterior perimeter area, there are two dogs, and Licensee's adult child and their two children are residing in the home. Licensees stated the plan of operation/program design does not specifically state the facility is owner operated with children and pets in the home. Staff interviews revealed that outdoor surveillance cameras were installed in early 2024. Resident interviews confirmed there are dogs and children living in the facility. Based on record review of approved plan of operation, the findings indicate changes to the plan of operation i.e. licensee daughter and kids, two household dogs, and installation of outdoor surveillance cameras were not reported to CCLD or the Regional Center. Therefore, there is evidence to support the allegation.

Allegation: Staff did not meet client's needs. The complaint alleges that resident (R1 &R2) did not have file documentation of R1's prostate exam and R2's gynecological exam records. Staff and residents were interviewed. The findings indicate that residents are taken to annual physician appointments where prostate and gynecological exams are recommended and/or performed. In R1's case, the resident stated they refuse to have a regular prostate exam, but their physician checks blood work for prostate issues. Resident (R2) stated their sister takes them to gynecological exams. Administrator stated the exams are conducted, but physician documentation was not obtained or filed, and there is no section on the Physician's Report that specifically addresses a prostate or gynecological exam. Based on record review, Licensee/Administrator obtained proof of exams after the Regional Center issued a Corrective Action Plan (CAP).

Allegation: Staff did not meet training requirements. The complaint alleges staff (S2) had not completed 8 hours of required annual CEU training from an accredited institution or professional. Staff (S2) stated they did not have the CEU training. Administrator stated monthly training is conducted, but they did not know the 8 hours of CEU training had to be conducted by an outside source. Based on record review, the findings indicate staff (S2) did not meet the 8-hour CEU training requirements.

Based on interviews conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . Deficiencies are cited according to Title 22. See LIC 9099D. Exit interview was conducted with Guadalupe Sahagun. A copy of the report and appeal rights were provided.