Complaint Investigation Report

C1 is also described by staff as needing a lot of attention and seeks a relationship with male clients. Staff informed LPA that there is typically 1 staff at Casa Feliz for 4 clients. Staff interviews also reveal that staff have lost track of C1 while assisting C4. C4 will require standby assistance while in the bathroom to prevent any accidents from seizures. In one instance, staff reported C1 wandered outside the facility and towards neighboring facilities. Staff also reported C1 has attempted to enter other client’s room without permission. Staff #3 (S3) reported C1 has entered Client #2’s (C2) room without C2’s permission and attempted to enter C4’s room while C4 was in the shower. Staff #7 (S7) also reported C1 has attempted to enter C4’s room prior to C4 showering. S7 attempted to redirect C1 out of the room, but C1 refused and wanted to watch C4 shower. S7 also reported that while S7 was assisting C4 in the bathroom for about 20 minutes, C1 left the facility. Staff #6 (S6) also reports C1 leaving the facility to go to a neighboring facility. LPA Luong reviewed May 2021 through July 2021 incident reports. Incident reports reported that C1 has several physical altercations with Client #3 (C3).

Based on interview and record review, there is 1 staff for the 4 clients. While staff is assisting other clients, staff are unable to supervise C1. The allegation Staff do not properly supervise resident is deemed substantiated.

On the allegation: Staff do not report incidents to licensing. It was alleged that the facility did not report incidents to CCLD. LPA Luong’s interview reveal that S7 reported an incident where C1 ran over C2’s foot with a walker. In the same day, C1 also attempted to scratch Client #3 (C3) but was redirected by S7. C1 then grabbed C4’s shirt and would not let go. S6 reported that C1 has attempted to kiss other clients. Other staff also reported C1 making comments that make C2 feel uncomfortable. All of these instances posed a risk to the personal rights, health and/or safety of the clients.

LPA Luong reviewed May 2021 through July 2021 incident reports as C1 was admitted to the facility May 2021. CCLD did not receive a report regarding C1 aggressing towards C2 nor C4. Based on interview and record review, multiple staff described incidents not reported to CCLD. The allegation Staff do not report incidents to licensing is substantiated.

Exit interview conducted, 9099-D, a copy of report and appeal rights were emailed to Administrator/Licensee