Complaint Investigation Report

RM Paula stated to the LPA they were aware of a day that one of the two staff on duty had made a run to pick-up an order of pizza for the facility. RM Paula did state that this is not something the facility would be say was allowed, staff is needed on-site. An incident occurred recently, where a client (C1) swallowed batteries, a nail, and a tack/pushpin and was hospitalized due to swallowing the foreign objects. C1 is said to be on a close supervision by staff on duty, one of the two staff is assigned to follow C1 and monitor the client closely. Staff were unaware that C1 had swallowed the nail, batteries, and tack/pushpin until the client (C1) told the facility Administrator. C1 is to be in line of supervision due to client's behaviors. LPA obtained care plan and behavior intervention plan. RM Paula stated that the facility has lost four staff since October 2023, and it has been difficult to hire new staff. There were five clients in care during these two incidents that occurred, mentioned in the above write-up.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of Facility does not have sufficient staffing, has been substantiated.

Due to the substantiation of the allegation, a citation will be cited today, Personnel Requirements 80065 (a)Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.-see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Exit interview conducted with RM Paula Sifflet.