Complaint Investigation Report

Allegation #1: Staff are not assisting resident with transportation.

The complaint alleges that the facility staff are not assisting Resident #1 (R1) with transportation. (R1) is not receiving adequate transportation support for medical appointments, requiring (R1) to find alternative transportation independently.

On September 28, 2023, between 10:10 AM and 1:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Four (4) out of the five (5) staff members reported that transportation for residents had been unavailable for approximately four months due to mechanical issues or a lack of proper documentation for the facility’s Mercedes-Benz Sprinter van.

On September 28, 2023, between 10:10 AM and 01:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #3 (R1-R3). Three (3) out of the (3) resident members reported that staff informed them the facility van was out of commission for repairs and didn't have a current vehicle registration card. The resident must arrange alternative transportation using taxis or Uber rides, which are out-of-pocket costs for the resident and are non-reimbursable.

On March 29, 2025, between 09:25 AM and 11:45 AM, the Department interviewed resident members identified as Resident #4 through Resident #9 (R1-R9). Five (5) out of the six (6) resident members confirmed that the facility van was out of commission for several months in 2023 and had arrangements with family members to provide transportation services.

On March 29, 2025, between 11:50 AM and 12:30 PM, the Department interviewed staff members identified as Staff #6 and Staff #7. One (1) of the two (2) staff members recounted an incident from 2023 when the transportation van was rendered out of commission, impacting the daily routines and facilities operations. This unexpected breakdown had implications that extended inconvenience, affecting the staff's ability to transport individuals as needed efficiently.

The Department reviewed Resident #1 (R1)’s Residence and Care Agreement California (dated June 06, 2022). It outlined on page 9 subsection (G), title “Transportation,” indicated in part, "We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping, and recreational facilities within a 12-mile radius. (Evaluation Report continues LIC 9099-C)

This report serves as an amendment to clarify the finding. It does not supersede the complaint investigation findings reflected in the report created 03/29/25.