Complaint Investigation Report

Interview with Inland Regional Center Service Coordinator also stated that the facility is required to provide two staff members to supervise Resident #1 since September 2025.

On February 3, 2026, at approximately 1:40 PM, Licensing Program Analysts (LPAs), Robert Campbell and Yolanda Delgado conducted an inspection at the facility. During the inspection LPAs observed two staff members present at the facility. LPAs observed that Resident#1 was sitting on the living room couch with Staff#2. Staff #1 escorted LPAs around the facility for approximately 10 minutes. At the initiation of the inspection, only Resident #1 was present. During the inspection, three additional residents arrived at the facility and no additional staff were able to provide supervision due to staff not responding to their shift.

During the investigation, LPAs conducted a record review of payroll time in & time out documents and found there was not enough staffing for a 2:1 ratio requirement for Resident#1 on the following dates: 12/1-12/7/25, 12/8–12/14/25, 12/15-12/21/25, 12/22-12/28/25, 12/29-1/04/26, 1/05-1/11/26, 1/26-2/01/26; 2pm-10pm: 1/12-18/26, 1/19-1/25/26).

Based on the information obtained in regards to the allegation that staff did not provide adequate supervision to client in care resulting in hospitalization, is substantiated. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is substantiated. This is in violation of Title 22 regulations, which is a potential risk to residents in care. The facility will be cited.

An exit interview was conducted. A copy of the report, along with the LIC 9099-D and appeal rights were provided to Caroline Sibande/Administrator.