Complaint Investigation Report

Allegation: Facility is operating out of staff ratio. It was reported that there have multiple times in which the facility was understaffed with less than 7 direct care staff. According to information obtained it is alleged that on April 28, 2024, the AM shift only had a total of 5 staff and the night shift was also out of staff ratio. There are 3 residents in placement. Two (2) residents have a 2 to 1 ratio, and one (1) resident has a 3 to 1 staff ratio. Eight (8) staff were interviewed of which, 6 out of 8 staff confirmed that on April 28, 2024 there were only five (5) staff working the AM shift because 2 staff called off and 1 staff had a family emergency. Administrator covered the shift. Staff acknowledged there are supposed to be always a minimum of 8 staff [7 staff + 1 lead staff]. According to staff interviews there are habitual staff that call off often without advance notice for personal reasons or because assignments are posted and they do not want to work with the challenging resident(s). Staff stated that many call offs occur on Fridays, Saturdays, and Sundays. Staff stated Administrator offers incentives for staff so that they can cover extra shifts when there are staffing shortages.

Based on timecard reports and schedules between dates 4/1/2024- 6/20/2024 the findings indicate that the following shifts did not meet required staffing ratios: 4/1/24 10PM - 6 AM, 4/8/24 6 AM - 2PM, 4/8/24 10 PM - 6 AM, 4/14/24 10 PM - 6AM, 4/16/24 10 PM-6 AM, 4/26/24 2 PM - 10 PM, 4/28/24 6 AM - 2PM, and 4/28/24 10 PM - 6 AM. Eastern Los Angeles Regional Center Quality Assurance staff conducted a series of announced and unannounced visits on 7/17/24, 8/7/24, 8/9/24, and 9/6/24, as a result several substantial inadequacies were issued. Based on investigations findings, there is sufficient evidence to corroborate the allegation.

Allegation: Staff yell at a resident. It is alleged lead RBT lstaff (S1) yells "No!" when resident (R1) requests to go places, and yells at resident (R2) when the resident is crying. A total of 8 staff were interviewed. Staff (S1) denied the allegation and reported that a former staff got fired mid June 2024 for telling resident (R1) to shut up. Two (2) out of 8 staff interviewed stated they have heard staff (S1) yell at residents. Two (2) staff reported that they have witnessed 3 other staff address residents in an aggressive, loud tone, intimidating, and demeaning manner. According to staff interviews, staff (S1) easily got frustrated and lacked patience. Additionally, three (3) other staff that have been heard speaking of residents in an inappropriate manner i.e. saying resident (R2) needs a spanking or conversations about beating up a resident. Based on interviews conducted the findings indicate that at least 4 staff have failed to treat residents(s) with dignity and respect. The majority of resident yelling is done when the Administrator is not present or during shift changes. The findings indicate unprofessional staff conduct towards residents has been occurring, but due to favoritism only some staff have been disciplined. Staff interviews support the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED .

An exit interview was conducted with Eduardo Alvarez. A copy of the report and appeal rights will be mailed and emailed due to printing issues.