Complaint Investigation Report

Allegation: Facility vehicle is in disrepair LPA conducted a tour of the facility transportation van that was reportedly had recently removed seats to declare to state the van would be a ten-passenger van (1 driver and 9 passengers). LPA requested to review the inspections that have been conducted by California Highway Patrol. Lauren the Executive Director provided LPA with a copy of the chp343 titled Safety Compliance Report/terminal record update that was dated 2015 and indicated that the vehicle would be inactivate and defined as bus. Due to the capacity reduction in the van, annual inspections are not required. A further inspection of the van revealed that, the fire extinguisher was not secured and has the potential to roll around, there were also extra seat belts that were buckled from the seats that were removed and were found to be secured laying on the floor. There were some exposed wires Based on the facility vehicle is in disrepair is SUBSTANTIATED.

Allegation: Uncleared adults working at the facility. LPA conducted a review of the staff schedule, LIC 500 and compared it to the facility personnel report summary. LPA found there to be inaccuracies with the staff schedule and the LIC 500, as not all staff on the schedule were not indicated on the LIC 500. LPA observed for Staff #1 (S1) to be working at the at the facility, during LPA’s visit and is noted to have worked/been an employee since July 21, 2022, without having had obtained the proper clearance. S1 current status is "pending". As a result, LPA along with Executive Director Lauren and Assistant Executive Director Shannon escorted S1 off the community grounds, it was explained that they would be removed from the schedule until the proper clearance has been obtained. S1 stated that they were aware and was working on makingThe allegation of uncleared adults working in the facility is SUBSTANTIATED.

Allegation: Facility does not maintain accurate and complete resident and employee records/files. LPA conducted a review of seven (7) resident files of the 17 currently admitted to the facility. LPA observed for the resident files to have a completed physician’s report, preplacement appraisal, an assessment needs and services plan, emergency notification identification form, and Admissions agreement. LPA conducted a review of five (5) staff files according to the LIC500 there are a total of (15) staff. According to the table of contents the staff files are to include the training that the staff has received at initial employment and on going required training. LPA observed the following inconsistencies: 1 out of 5 staff files had a training checklist, 2 of the 5 staff records had a CPR/First Aid card showing that training had been received. 3 of the 5 staff files had a copy of the staff identification (DL, ID card). Based on record review the allegation of facility does not maintain accurate and complete resident and employee records/files is SUBSTANTIATED.