Complaint Investigation Report

When offered more staff hours, the Licensee stated they don’t have enough staff to provide those activities and hours to R1. Licensee also stated that R1 requires a higher level of care than the facility can provide due to the elopement and wanting outdoor activities, and wants to evict R1 on that basis. When interviewed, the Licensee stated they don’t feel comfortable having R1 in the facility due to elopement behaviors and want them relocated. LPA explained that the facility must meet R1’s needs. R1 has a behaviorist, but according to staff interviews, the behaviorist has not provided staff with strategies to help curb R1’s elopement and behaviors. LPA encouraged the Licensee to utilize all resources available to work on R1’s eloping behaviors, and to support R1’s preferred activities, including the one-on-one staff offered by Tri-Counties Regional Center. On 10/27/2022 LPA received an update that Tri-Counties Regional Center approved 292 hours per month of 1-on-1 support for R1 effective 10/1/2022. Tri-Counties stated that as of 10/27/2022 the facility has yet to hire someone or give R1 those hours. Documentation and interviews with staff revealed staff assist R1’s needs with assistance of medications, and prompting/set-up for showering and prompting using the bathroom. R1’s Individual Program Plan indicates R1 requires constant supervision as R1 occasionally tries to elope. R1’s Appraisal/Needs and Services Plan states at times R1 will become physically aggressive, yell at others, and/or attempt to elope when they are unhappy with their current environment or situation. The Plan states staff at Bauer will assist with implementation of the Plan. However, staff interviewed stated there has been no training or support to redirect R1 when R1 elopes/attempts to elope, and they struggle with supporting R1 with behaviors. R1’s Individual Program Plan indicates R1 is active and it is important to be able to exercise on a consistent basis, and R1 will be provided with opportunities to exercise every day and have staff that can keep up with R1. R1’s Appraisal/Needs and Services Plan states R1 will participate in exercise to maintain optimal health. The Plan states staff at Bauer will assist with implementation of the Plan. Interviews revealed staff do not assist R1 with exercise every day. Additionally, during the investigation, LPA discovered the facility was restricting visitation for R1 by not allowing R1 to have overnight/weekend visits with family, and cited COVID-19 restrictions and behaviors were the reason. LPA notified Administrator and Licensee on the 9/8/2022 visit that COVID-19 visitation restrictions were lifted and they cannot prevent R1 from having visitation, as long as they follow current guidance. Based on documentation and interviews, staff are not supporting R1 with needs listed in their Plans. Therefore the allegation is deemed Substantiated at this time.

On the allegation: Facility is unlawfully evicting resident. Interviews revealed that the facility gave Tri-Counties Regional Center and Resident 1’s family a 30-day eviction notice dated 08/28/2022 and did not send a copy to Licensing, which is required per regulation 85068.5. Continued on 9099-C