Complaint Investigation Report

Regarding the allegation that client file records are missing and/or incomplete: it was alleged that client files do not contain documentation of vocational services provided. LPA reviewed the Continued Care Plans for C1, C2, and C3, which show the clients’ educational and vocational goals, but do not document the steps necessary to reach these goals, the progress of the clients towards reaching these goals, or the services provided by the facility towards reaching these goals. LPA interviewed CD who admitted the allegation and stated that the facility is already updating its processes to document the steps the clients will take to reach their educational and vocational goals and the services provided to the clients at the facility to reach these goals. The information obtained corroborated the allegation.

Regarding the allegation that facility staff are not adequately trained: it was alleged that the staff file for S1 did not contain records showing S1 was trained in the preparation of discharge plans and the staff files for multiple staff did not contain records of 20 hours of continuing education per year. LPA interviewed CD who admitted the allegation and stated S1 has been preparing discharge plans for a long time. LPA reviewed the training records for S1 which corroborated that S1 did not have documented training on preparing discharge plans. LPA reviewed the facility’s 2024 training records which corroborated that four staff did not complete 20 hours of continuing education in 2024. The information obtained corroborated the allegation.

Regarding the allegation that facility does not have a Program Director: it was alleged that the facility does not have an approved program director. LPA interviewed CD who admitted that the prior program director left in 2024 and the facility still does not have an approved program director. 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.