Complaint Investigation Report

It was alleged that facility did not follow Day Staff Ratio implemented by RCOC. LPA Rodriguez conducted 4 out of 4 interviews with staff, of which all 4 interviews did not corroborate with the allegation. Per staff interviews, client 1 (C1) required 1:1 supervision, however was placed on a 2:1 supervision as of 4/10/2024. During the tour of the facility, and upon LPAs entrance of the facility, LPA observed a total of 4 staff members on duty, of which 2 staff members were specifically attending to C1. Per review of the facility LIC500 dated for April 2025, there are a total of 4 caregivers scheduled from 8:00AM-2:00PM, 4 caregivers from 2:00PM-10:00PM, and three caregivers from 10:00PM-8:00AM, along with 4 administrators who are on-call 24-hours. Per record review, Regional Center issued the facility a New Referral Moratorium on July 28, 2025, of which the allegation for insufficient staffing from 1/28/2025, was substantiated.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.

An exit interview was conducted with LE Villegas.

A copy of this report was explained, and appeal rights were provided during the visit.