Complaint Investigation Report

On 10/17/2024 LPA conducted a visit to the facility to initiate investigation into the above allegation. LPA reviewed the posted menu. LPA observed the menu selections for 10/17/2024: carrots, humus and oranges for snacks, spaghetti and meatballs for lunch and beef with stuffed peppers for dinner. LPA obtained photos of the refrigerator, freezer and pantry contents as well as the posted menu. Based on observations, LPA determined the facility did not have carrots, humus or oranges in the facility on 10/17/2024. Based on interview with one staff and the administrator, the facility did not have the ingredients for the stuffed peppers that night. Based on interview with one staff and the administrator, the post menu does not reflect all of the meals that end up being served. Based on interview with Administrator, the selections posted for lunch indicate the meals facility staff plan to prepare for clients to take with them to Day Program for lunch.

On 11/1/2024, LPA returned to the facility. LPA obtained a photo of the current week's menu and conducted interviews with Administrator, staff and clients. Based on interviews with 4 clients, 4 out of 4 stated the facility is following the posted menu. LPA observed 4 out of 4 clients having a sausage croissant sandwich and fruit for breakfast. On this day the posted menu indicated clients would be having a breakfast egg sandwich and fruit for breakfast. Based on interviews with one staff and four clients, one staff and three clients stated the facility had spaghetti and toast for dinner on 10/31/2024. The planned dinner for 10/31/2024 on the posted menu reads "Hamburger choice of toppings salad w/ carrots and cucumbers"

Based on interviews conducted, records reviewed and observations made, LPA determined that the facility is not following the posted menu as outlined by the above Title 22 Regulation. LPA observed items necessary for some 10/17/2024 posted menu selections were not present in the facility on 10/17/2024. Staff and clients stated dinner served on 10/31/2024 was a meal that was not posted on the menu for 10/31/2024 dinner.

The preponderance of evidence standard has been met. The allegation of Facility is not following the posted menu is determined to be SUBSTANTIATED, meaning the complaint allegation is valid and that a violation has 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.