Complaint Investigation Report

Allegation: Licensee did not ensure there is adequate staffing and supervision. It was reported that the facility did not have a current weekly staff schedule and discrepancies in recorded hours were observed. Based on record review, the findings indicate that on August 20, 2024 review of staff schedules revealed staff hours worked were not accurate i.e., several hours of staff coverage were unaccounted for. The staff schedule did not list any scheduled overnight staff. Licensee assumed that the live-in staff met staffing requirements, even though their shift ended at 10 PM. The facility has 2 live-in staff, but one of the staff only works Sundays. Prior to August 30, 2024, there were only 6 staff employed. On August 30, 2024, Licensee hired 2 additional staff to work the NOC shift. All four staff confirmed that there was not any NOC shift staff employed prior to 8/30/24, but stated that there is always a staff present in the home. Two (2) residents were interviewed. The residents were unable to provide details about staffing. The facility is a level 3 home. The staff to individual ratio is 1 to 4, and during outings it should be 2 to 4 for additional support. The Regional Center issued a Corrective Action Plan on August 29, 2024. There is sufficient evidence to corroborate the allegation because the 2 live-in staff (S3 & S4) were not being compensated for overnight shifts, were not awake at night, potentially resulting in inadequate supervision.

Allegation: Facility staff does not provide a safe environment for clients. It is alleged the facility is posing a risk and violating client rights by having a lockable doorknob on the entrance to the kitchen, and client (C1's) bed obstructed the exit door in the room that leads into the backyard. All staff confirmed that client (C1's) bed obstructed the exit room door, but stated that the bed and chair have been rearranged in the room and are no longer obstructing the exit door. Client (C1) confirmed their bed obstructed the room exit door. During today's visit, the bed was not observed to be obstructing the room exit door. Additionally, staff stated that the kitchen door had a lockable handle in order to prevent client (C2) from exiting at night to smoke, and also to prevent client (C3) from going to the refrigerator to get milk. Client (C3) has a dairy allergy. According to HCBS rule, there should not be a lockable door knob to enter the kitchen. During today's visit, the kitchen door knob was observed to no longer have a lock. The Regional Center issued a Corrective Action Plan on August 29, 2024. There is sufficient evidence to corroborate the allegation.