Complaint Investigation Report

It states that a staff will review C2’s progress during individual therapy sessions twice a week. LPAs reviewed the weekly session notes for C2 and observed that on October 8, 2025, it does not document C2’s progress towards reaching the established goal of reducing their focus on manic thoughts from eight hours per day to three hours per day within two weeks. Additionally, LPAs observed that individual therapy sessions with C2 were only completed once a week, when C2’s treatment plan states that individual therapy sessions will be conducted twice a week. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff do not meet the minimum requirements, the following has been concluded: Per California Code of Regulation under Personnel Requirements 81065 (n), it states that all direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i). These requirements include that all direct care staff shall have graduated from high school or possess a GED and have a minimum of one year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities. Such experience shall be in direct services to clients. If the employee does not have the required experience, the program shall document a specific plan of supervision and in-service training for the employee which will guarantee the ongoing qualification of the employee to perform the job. The plan should include but not be limited to the frequency and number of hours of training, the subjects to be covered, and a description of the supervision to be provided. LPAs reviewed five staff files. LPAs observed that five out of the five staff did not meet the one year of full-time experience requirement, thus requiring an appropriate plan of supervision. LPA reviewed the plan of supervision for all five staff. LPAs observed that the plan of supervision for all five staff states the training that the staff will complete within the first ninety days of employment. However, the plan of supervision does not describe how the facility will ensure ongoing qualification for the staff to perform the job, including details about number of hours of training, the subjects to be covered, and a description of the supervision to be provided after the first ninety days of employment for the staff. Based on the evidence gathered during this investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that, facility staff did not complete the required training hours, the following has been concluded: Per California Code of Regulation under Personnel Requirements 81065 (r)(2), it states that all direct care staff shall receive a minimum of 20-clock-hours of continuing education per year, which shall provide the staff with the knowledge and skills as appropriate to their job assignment. CONTINUED ON LIC9099-C