Complaint Investigation Report

Regarding the allegation that the facility is not following its plan of operation: it was alleged that C1’s written assessment did not include documented evidence of current vocational limitations, that their meal planning, budgeting, and shopping skills were not assessed, that the facility was not conducting ongoing review of progress towards reaching established goals, that the treatment/rehabilitation plan was not completed by staff, and that the discharge summary for C2 and C3 did not contain documented evidence of goals accomplished and referral for follow-up plans. LPA reviewed the facility’s plan of operation which corroborated that the plan of operation required that all these steps be completed. LPA interviewed CD who admitted the allegation and stated that the facility has updated their processes and conducted training to address these issues moving forward. LPA reviewed C1’s Biopsychosocial Assessment dated June 20, 2024 and Treatment Plan documentation which corroborated the allegation. LPA reviewed C2’s and C3’s Discharge Summary and Aftercare Plan/Discharge Instruction Form which corroborated the allegation.

Regarding the allegation that facility staff are not qualified: it was alleged that five staff files did not contain documented evidence that these staff had one year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities or a documented plan of supervision. LPA interviewed CD who admitted the allegation and stated that these five staff had been promoted into these positions prior to obtaining the required experience and did not have proper plans of supervision, but that the facility has placed these staff on plans of supervision moving forward. LPA reviewed Staff Plan of Supervision Records which corroborate that these five staff did not have the required experience when they started their position or a plan of supervision, but that the facility has corrected the issue moving forward.

Regarding the allegation that facility staff are not adequately trained: it was alleged that the staff preparing the admission assessments, treatment/rehabilitation plans, and discharge summaries had not received training in the development of these documents and that eight staff did not have documented evidence of 20 hours of annual training. LPA interviewed CD who admitted the allegation and stated that the document preparation training had been done but was not documented and that eight staff had not completed the 20 hours of annual training in 2023, but that all these issues have been resolved moving forward. LPA reviewed Staff Training Records which corroborated this 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.