Complaint Investigation Report

operating outside of their fire clearance. Since the fire clearance, there has been a small room/office that was built out of the garage and is now being used as staff living quarters.

LPA reviewed the facility’s staffing schedules from December 2023 to present. Based on the staffing schedule and staff interviews, LPA has determined that this facility has insufficient staffing. This is a level 4-I home which is required to have awake overnight staff. There is only one staff during the overnight shift who goes to sleep after the clients have all ‘settled down for the night’. This facility is required to provide 144 awake staffing hours per week. Therefore, this facility is operating with insufficient staff and is not staffing according to their agreement with ALTA Regional Center.

Allegation: Facility is not reporting incidents

LPA reviewed an incident report submitted to ALTA Regional Center regarding R4’s behavior on 3/8/2024. R4 told staff that he could not sleep. Staff provided R4 with a PRN sleep aid medication. R4 later became aggressive and became combative with staff. This incident was not reported to the Department. LPA only became aware of the incident while reviewing R4’s file. Therefore, LPA has determined that the Facility is not following reporting requirements.

Deficiency cited on 9099-D. Appeal rights were printed and given.

Exit interview conducted. A copy of this report was left at the facility.