Complaint Investigation Report

It was alleged that the facility was operating with nine (9) clients, yet the licensed capacity is six (6) clients. Upon arrival, LPA observed seven (7) clients at the facility. Five (5) clients were in the living room, one (1) was in their bedroom, and one (1) was in the office with a staff member. The facility has four (4) bedrooms of which two (2) are designated as shared rooms and two (2) are designated as private rooms. However, LPA observed that the private rooms were being used as shared rooms; three (3) bedrooms had two (2) beds and one (1) bedroom, Bedroom #3, had three (3) beds. Per California Code of Regulations, Title 22 section 81087(e)(1) Buildings and Grounds, “Bedrooms must meet, at a minimum, the following requirements: (1) No more than two clients shall sleep in a bedroom unless the program justifies a group living arrangement of more than two persons to a room and such arrangement is approved in writing by the licensing agency.” The facility does not have departmental approval for a group living arrangement nor for operating with more than six (6) clients. LPA observed the facility license and program approval from Department of Health Care Services posted on the entryway wall which state that the facility’s total capacity is six (6). Facility does not have fire clearance for more than six (6) clients. Staff interviews and record review confirmed that there were nine (9) clients living in the facility and that two (2) clients discharged in the morning prior to LPA’s arrival, which dropped the census to seven (7). Administrator stated that the facility has been over capacity for about a month and staff confirmed. Based on observation, interview, and record review, the allegation “Facility is operating over capacity” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty was assessed in the amount of $500 for fire clearance violation. Administrator was informed that failure to correct the deficiency may result in additional civil penalties.

Exit interview conducted. Appeal rights and a copy of the report was provided.