Complaint Investigation Report

During the visit, LPA Haddadin observed four staff members on duty while the facility housed four clients. Client 1 (C1) required a 2:1 staff-to-client ratio, and Client 2 (C2) required a 1:1 staff-to-client ratio. LPA Haddadin observed only one staff member assigned to care for C1 throughout the entire visit.

It was further noted that the facility had previously received a New Referral Moratorium from the Regional Center of Orange County (RCOC) on July 28, 2025. This action was taken following the identification of violations that resulted in the issuance of Corrective Action Plans (CAPs). The prior violations included two Special Incident Reports (SIRs) concerning Client 1 (C1). The first SIR alleged neglect and a failure to protect from a health and safety hazard after C1 used a chair to access a locked, elevated cupboard. According to C1’s Plan of Service (POS), a 2:1 staffing ratio is required twenty-four hours per day, seven days a week. The allegation was substantiated by RCOC as the required second staff member was not present with C1 at the time of the incident.

A second SIR was received on February 7, 2025, alleging a client rights violation due to insufficient staffing, which was observed by a reporting party and C1’s mother on January 28, 2025. An unannounced visit by RCOC and additional representatives on February 10, 2025, determined that staffing levels were inadequate to meet client needs. These findings were discussed with Administrator Noel Villegas and confirmed by the RCOC Associate Director of Housing. The allegation of a client rights violation due to insufficient staffing was also substantiated by RCOC.

Based on the documentation obtained and reviewed by LPA Haddadin, the preponderance of evidence standard has been met. Therefore, the allegation that the “Facility did not follow the Day Staff Ratio implemented by the Regional Center of Orange County (RCOC)” is SUBSTANTIATED. This constitutes a violation of Title 22, Division 6, Chapter 6, Section 85065.5(a)(1).

An exit interview was conducted with facility staff, and a copy of this report, along with appeal rights, was provided to Administrator (AD) Arnold Andel.