Complaint Investigation Report

Per documentation review, LPA observed that each client present, had a signed Admission Agreement, of which all clients interviewed also verified that the admission agreement is being followed.

It was alleged that the facility is operating understaffed. 3 out of the 3 client interviews did not corroborate with the allegation by stating that all needs are met and that there are a total of two staff members present at all times at the facility, and denied of any safety and health concerns. 1 out of the 1 staff interview did not corroborate with the allegation by stating that staff 1 (S1) and staff 2 (S2) are on duty “twenty-four-seven” due to S1 and S2 being live-in staff. LPA reviewed the facility schedule and observed that only S1 and S2 are actively present at the facility, however there are additional staff also available if needed.

It was alleged that the facility is falsifying personnel records. 3 out of the 3 client interviews did not corroborate with the allegation. 1 out of the 1 staff interview did not corroborate with the allegation by stating that all training is valid. Per documentation review, LPA contacted the training agencies on file and was able to verify that the personnel records are valid and legitimate.

It was alleged that the facility did not maintain accurate Personal and Incidental (P&I) Funds records.

3 out of the 3 client interviews and 1 out of the 1 staff interview did not corroborate with the allegation by stating that the facility staff keeps track of each client’s P&I funds via P&I form. Per documentation review, LPA calculated the P&I funds for all clients present at the facility and observed that the amount of funds matched with the form per client, and that the facility notes every time a client is given their P&I funds.

Based on LPA’s interviews which were conducted, review of documents obtained, and observations, LPA is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

An exit interview was conducted with AD Mora and a copy of this report was provided and explained.