Complaint Investigation Report

Regarding the allegation, "Staff did not provide resident with food", it was alleged that staff refused to provide R1 food, upon request. Interviews with staff and residents were inconsistent, however, all interviews confirmed that residents are given breakfast, lunch, dinner, and two snacks per day at 3pm and 7pm. All residents interviewed consistently stated that they are not given food outside of these specified times if requested. Outside source interview corroborated that R1 was not provided an adjusted lunch or between meal snacks after returning to the facility from meeting with a service provider, which resulted in the resident having to wait hours until being served the next meal.

Regarding the allegation, "Resident(s) were not accorded dignity", it was alleged that staff behaved inappropriately and were rude to clients. Staff interview revealed that Staff 1 (S1) engaged inappropriately with R1 during multiple occasions, escalating arguments instead of de-escalating them. Staff interview revealed that S1 was terminated for this behavior. Staff and resident interview revealed that S2 regularly swore in conversation with residents. Four outside sources interviewed directly observed different staff members being rude to and yelling at residents, instigating letters of concern and meetings to address the issues with the facility. Review of facility records confirmed that S2 swore in conversation with R1 and was asked by R1 not to use profanity when talking to them.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Monica McDade, Program Manager, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.