Complaint Investigation Report

Allegation: Lack of Care and Supervision resulting in the client becoming malnourished

The complaint alleged that the facility placed the client on a liquid diet despite their ability to consume solid food, leading to significant weight loss for the client.

On October 7, 2025, at approximately 11:00 AM, LPA Richard reviewed the Physician's Report for Community Care Facility (ARC), also known as LIC 602, for Client 1 (C1). The report, dated July 21, 2021, indicated that C1 should be placed on a special diet. A review of the Physician's Order dated February 28, 2022, specified that C1 should follow a Puree Diet and may have 2 scoops of organic vegan protein powder in 8 ounces of water once a day. LPA also examined C1's weight chart covering the period from December 17, 2021, to March 6, 2022. It was noted that C1's weight has remained unchanged since the initial admission to the facility on 05/10/2021.

On October 7, 2025, at approximately 11:00 AM, Licensing Program Analyst (LPA) Antonine Richard interviewed the former administrator (A). The former administrator stated that the staff adhered to the doctor’s orders when serving clients, particularly those on special diets. According to A, the facility had an abundance of food, ensuring that clients would not be deprived of meals.

At around 11:30 AM on the same day, LPA Richard interviewed the current administrator (A1), who confirmed that a physician had prescribed a pureed diet for a client and that the facility staff only followed this physician's order. Later that day, LPA Richard spoke with the CEO of the facility, who denied the allegations. The CEO explained that the facility maintains a weight chart and conducts weekly weight checks for each client. If a client is found to be losing weight, the facility promptly informs the physician. Which was not the case for C1.

On October 7, 2025, at approximately 11:30 AM, an interview was conducted with facility staff members (S1 and S2). They confirmed that client C1 was on a pureed diet. C1 had no issues with the pureed diet, and if C1 wanted to eat something, it was pureed accordingly. S1 also noted that C1 had difficulty swallowing, and at times, even drinking water posed a challenge for C1.