Complaint Investigation Report
During this visit, LPA obtained a LIC500 Personnel Record which indicates that Staff 3 (S3) works Sunday at 7:00 AM through Thursday at 9:00 PM; Staff 4 (S4) works Friday 7:00 AM through Sunday at 9:00 PM; and Licensee and Staff 5 (S5) work varying hours as needed. On Monday, 09/29/2025, LPA observed S3 leave the facility at approximately 11:30 AM; Licensee left the facility at approximately 11:30 AM to obtain paperwork; and S4 did not arrive at the facility until approximately 12:10 PM, leaving three clients and no staff present in the facility during this time.
On 06/19/25 and 09/29/2025, all four client interviews conducted revealed that clients are left unsupervised for brief periods of time when change of shift occurs and when a staff needs to leave early or arrive late. These interviews also revealed that clients are sometimes asked to "keep an eye" on another client while staff are away. On 06/19/2025, LPA obtained a copy of each client's LIC602 Physician's Report which indicates that each client is able to leave the facility unassisted. LPA explained to licensee that this means that they are able to be out in the community unsupervised but does change the regulatory requirement that a staff person shall be present in the facility at all times. Additionally, LPA explained that per regulation " [c]lients shall not be used as substitutes for required staff." Licensee conveyed understanding and agrees to operate in compliance with this regulation at all times.
Based on observations made, interviews conducted and records obtained, the allegation that the facility is not staffed appropriately is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).
***An Immediate Civil Penalty in the total amount of $500 is being assessed for the observed clients being left at the facility without staff present, which is a violation of personnel requirements and an immediate health, safety, and/or personal rights violation to persons in care, (see LIC421IM).***
Exit interview conducted with Licensee, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Licensee.
Source: California Department of Social Services, Community Care Licensing. Methodology · Report a correction