Complaint Investigation Report

Regarding the allegation that the facility is not following its plan of operation: it was alleged that a written assessment for C2 was not completed on admission, C1’s written assessments did not include medical needs, C3’s written assessments did not include meal planning, budgeting, and shopping skills as assessed on admission, C2’s Treatment/Rehabilitation Plan was not prepared with the client, and the Treatment/Rehabilitation Plans for C1, C2, and C3 did not include methods to evaluate achievement of goals. LPA inspected the facility and conducted health and safety checks on the clients present and observed no health and safety issues. LPA reviewed the facility’s plan of operation which states that clients’ assessments will include medical needs, meal planning, budgeting, and shopping skills, that clients’ Treatment/Rehabilitation Plans will be prepared with the clients and within 72 hours of admission, and that clients’ Treatment/Rehabilitation Plans will include methods to evaluate the achievement of goals. LPA reviewed C1’s Biopsychosocial Assessment dated July 22, 2024, which did not include medical needs. LPA reviewed C3’s Biopsychosocial Assessment dated September 14, 2024, which did not include meal planning, budgeting, and shopping skills as assessed on admission. LPA reviewed C2’s Treatment/Rehabilitation Plan dated September 30, 2024, which was completed late and not with the client because C2 was admitted on September 19, 2024. LPA reviewed C1’s Treatment/Rehabilitation Plan dated July 26, 2024, C2’s Treatment/Rehabilitation Plan dated September 30, 2024, and C3’s Treatment/Rehabilitation Plan dated September 19, 2024, which did not include methods to evaluate achievement of goals. LPA interviewed AD, PD, and CD who admitted the allegation and stated the facility has already taken measures to address these issues. The information obtained corroborated the allegation. Regarding the allegation that facility staff did not properly complete clients’ assessments: it was alleged that the Treatment/Rehabilitation Plans for C1, C2, and C3 were not completed within 72 hours of admission. LPA reviewed C1’s Treatment/Rehabilitation Plan dated July 26, 2024, which was completed more than 72 hours after C1’s admission on July 20, 2024. LPA reviewed C2’s Treatment/Rehabilitation Plan dated September 30, 2024, which was completed more than 72 hours after C2’s admission on September 19, 2024. LPA reviewed C3’s Treatment/Rehabilitation Plan dated September 19, 2024, which was completed more than 72 hours after C3’s admission on September 12, 2024. LPA interviewed AD, PD, and CD who admitted the allegation and stated the facility has already taken measures to address these issues. 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.