Complaint Investigation Report

Allegation: Staff do not ensure residents receive therapy sessions. The complaint alleges the facility was out of compliance in providing 7 hours of behavior consultant services for individuals in the home during the months March 2025 - June 2025, and between months October 2024, December 2024, and January 2025. Per record review, it was noted that on February 21, 2025, Regional Center Quality Assurance Specialist documented the concern and made the recommendation that Administrator shall ensure 7 hours of monthly consultant hours are provided to all individuals. However, on August 20, 2025, during the Regional Center annual review it noted that the issue with consultant hours was not fulfilled. The findings indicate the licensee did not provide a minimum of 7 hours a month of consultation hours per individual as noted on the program design and Regional Center contract.

Staff interviews revealed that consultant hours in physical therapy services did not meet the required contracted 1 hour. During several months the physical therapist was short 45 minutes in PT services to individuals, but billed the entire hour. It is unknown if the physical therapist was visiting the facility at times in which the individuals were not present. Staff stated that the program design states 7 hours of consultant services, which includes that a behavior consultant, nurse consultant, and physical therapist shall be provided services for each individual. Staff stated that nurse and behavior consultant hours were not impacted. On September 10, 2025, the Regional Center issued a Corrective Action Plan (CAP) that states the facility was out of compliance and was not providing the agreed upon consultant hours.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Pursuant to Title 22, California Code of Regulations, a deficiency was cited.

Exit interview was conducted with Quality Assurance Director Claudia Lujan and a copy of appeal rights and report was issued.