Complaint Investigation Report

Per record review and staff interviews, on October 1, 2025, C1 arrived at their day program complaining of stomach pain. The staff at the day program reached out to the facility staff asking for C1 to be picked up. Facility staff were unable to pick up C1 at the time and asked the day program staff to transport C1 to the hospital via emergency services, to which day program staff did later that afternoon. Internal interviews revealed that there were three (3) staff members at the facility at the time C1 was asked to be picked up. Two (2) of the three (3) staff members were on site at the facility with Client #2 (C2). Per interviews, C2 had a Regional Center specified staff-client ratio of two (2) staff members to one (1) client. The third staff member was at an appointment with Client #3 (C3).

Review of C1’s physician’s report dated June 11, 2025, revealed that C1 had the capacity for self-care and could leave the facility unassisted. Interviews corroborated C1’s capacity for self-care thus explained the reasoning as to the facility staff requesting day program staff to transport C1 via emergency services if C1 was having a medical emergency.

Based on interviews and records review, the investigation did not yield a preponderance of evidence to conclude that staff did not provide transportation to clients. Based on the foregoing, the allegation is unsubstantiated. This finding means that although the allegation may have happened or may be valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted with House Manager Innocent Okwudifele, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.