Complaint Investigation Report

Regarding the allegation that the facility is not following its plan of operation: it was alleged that the written assessment for C1, C2, and C3 did not include documented evidence that their meal planning was assessed, that the facility was not conducting ongoing review of progress towards reaching established goals with regards to C1 and C3, that the treatment/rehabilitation plan was not completed by staff for C1 and C3, and that the discharge summary for C4 and C5 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 the Biopsychosocial Assessments and for C1, C2, and C3 and Treatment Plan documentation for C1 and C3 which corroborated the allegation. LPA reviewed C4’s and C5’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 two 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 two staff had not obtained 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 two 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 not received training in the development of these documents and that five 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 five 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.