Complaint Investigation Report

LPA conducted interview with Administrator (AD) Villegas and two staff. AD admitted there was one incident in which Client 1 (C1) was sent to Day Program with soiled clothes from the day before in their backpack. AD reported staff forgot to remove C1’s soiled clothing from the day prior. Two of two staff were unable to confirm or deny that C1 was sent to Day Program with soiled clothes in their backpack. AD and two of two staff stated C1 is normally sent with a change of clothes due to repeated instances of soiling their self. Following the incident AD reported reminding staff to regularly check C1’s backpack prior to attending day program.

On November 25, 2024, LPA conducted a collateral visit to C1's Day Program. LPA conducted interviews with three Day Program staff, of which two staff at the Day Program stated they noticed sometimes C1 would be sent to Day Program with pants that were too big and no belt causing C1’s pants to be falling and the belt not fitting. At least one staff reported C1 would arrive very dirty and would smell. Two staff confirmed having knowledge of C1’s water bottle having mold in it. Interviews conducted report the Day Program advised the facility to clean or replace C1's reusable water bottle due to stains present on the water bottle. Per interviews conducted, once communicated the facility complied.

Based on interviews conducted, LPA determined the facility did not ensure that client was free from humiliation that interfered with daily living functions and the facility did not ensure that all food is safe in quality.

The preponderance of evidence standard has been met. The allegations are determined to be SUBSTANTIATED, meaning the complaint allegations are valid and that two violations occurred. An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099, deficiency page and appeal rights were provided to the facility.

LPA was able to verify the facility conducted two in-service training on November 8, 2024 regarding personal rights and safe food service. LPA was able to clear to two deficiencies during the visit. LPA provided clear letters to the facility.