Complaint Investigation Report

When asked if there was a staff that did anything that made them feel uncomfortable, 15 out of 20 staff stated Staff 1 and 10 out of 20 stated Staff 2 (S2). Staff interviewed stated S1 is very rude, cocky, over prompts C1, has a negative tone of voice, and often gets frustrated with staff and C1. Staff interviewed stated S2 is bossy, says they’re “over it”, and prioritizes their office job away from clients over helping staff with C1. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility is operating out of staff ratio. It was alleged Staff 2 (S2) leaves staff on the floor by themselves or with an uncleared trainee and goes in the office to work unless they are asked for help. Interviews reveal that multiple staff have reported that Staff 2 has left them alone or with another staff to do work in the office all day. One staff stated that they don’t feel comfortable telling S2 that they need to stay on the floor when the staff are out of ratio. Staff interviewed indicated it is very clear that C1 requires 2 staff at all times per C1’s care plan, and that all staff know the priority is to be in the 2 to 1 ratio to ensure C1 is safe and adequately cared for. Staff interviewed stated they knew office work is secondary and they should stay on the floor to maintain ratio, without being asked. Another staff stated they said they needed help and was not comfortable being alone on the floor. Staff stated that S2 said “I’m needed in the office” and walked away, leaving C1 out of ratio. Two staff stated they asked S2 for support on 3/21/23 because one staff was new and in training, and was not cleared to count in the ratio yet. Staff reported S2 said that the staff had been clear per the Administrator and left them alone and went to the office, leaving them out of ratio. Interview with S2 revealed that they thought the new staff was cleared to work, then stated the Administrator informed them they were not and still in training. S2 stated they then were on the floor, in ratio, until C1 went to sleep. S2 said after C1 went to bed they went to the office and told the two staff to call if they needed help, knowingly leaving C1 out of ratio. Based on the information obtained, the allegation, Facility is operating out of staff ratio is Substantiated at this time.

On 4/7/23 the facility placed staff 1 and 2 on a leave of absence while they conducted an internal investigation. On 6/20/23 the facility informed LPA that they concluded their investigation and that Staff 1 was terminated and Staff 2 was removed from their supervisor role and will be transferred to another facility.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D).

Exit interview conducted, copy of report, citations, and appeal rights issued.