Complaint Investigation Report

Regarding the allegation that staff did not follow clinical recommendations for clients: it was alleged that one client did not receive the clinically recommended number of primary care consultation in March 2025 and physical therapy in January 2025 and that all three clients did not receive the clinically recommended number of dietician consultation hours in March 2025 and April 2025. LPA interviewed PA who admitted the allegation. Per PA, C1 did not receive the required number of primary consultation hours in March 2025. LPA reviewed C1’s care plan which indicates they should receive 10 hours of primary care consultation per month. Per C1’s consultation logs, C1 only received 3 hours and 15 minutes of primary care consultation hours in March 2025. Per PA, three clients have dietician consultation services in their care plans, but the clients did not receive dietician consultation services in March 2025 and April 2025 and the facility does not have consultation logs for these services. LPA reviewed the care plans for three clients which confirm they should be receiving dietician consultation services. The information obtained corroborated the allegation.

Regarding the allegation that documentation for clients' is not being maintained: it was alleged that the consultation logs were not available for one client’s psychiatry consultation for November 2024. LPA interviewed PA who admitted the allegation, stating that while C1 likely received the required number of psychiatry consultation hours in November 2024, these consultation hours were not documented in C1’s file and the consultation logs for these hours do not exist. The information obtained corroborated the allegation.

During the course of the investigation, the Department obtained sufficient evidence to substantiate the allegations mentioned above. The preponderance of evidence standard has been met; therefore, the above allegations are Substantiated. See LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.