Complaint Investigation Report

Facility records and Program Director report that, on April 4, 2022 at approximately 9:00AM, Client 1 (C1) arrived at the facility with a backpack that contained their lunch, and usually leaves the day program at approximately 2:30PM. Program Director also said that lunch is usually eaten around 11:30AM. A review of outside source records revealed that C1 is able to eat without assistance. But, Program Director, stated that C1 requires assistance in taking out their lunch from their backpack, serving, and heating up C1's meal. An interview with Program Director revealed that C1 was inadvertently not fed lunch due to C1 requesting to use the restroom numerous times before and during lunch. C1 requested the restroom 5-6 times before 10:30AM and 9 times from 10:30AM to 11:15AM which, outside sources noted, is an avoidance behavior. Program Director also reported that during lunch, there were several events that required prioritization that led to staff not being aware that C1 was not fed. A Special Incident Report from the facility advising the Department that staff did not provide C1 with a meal during lunch, received on April 6, 2022, corroborates the described events of April 4, 2022 as well as outside source interviews.

Based on interviews and records review, the evidence obtained during the complaint investigation, the allegation that the licensee did not ensure that the client was fed is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the allegation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with Program Director. An exit interview was conducted with Program Director; LIC9099C, LIC9099D, the plan of correction, a copy of this report, and Licensee's Rights (LIC9058) were provided.