Complaint Investigation Report

On the allegations – Licensee failed to follow Plan of Operation in regards to client services and Staff failed to provide client services required in their services plan.

It was alleged that staff refuse to provide groups on a consistent basis and the facility failed to provide services as outlined in the facility’s program plan and client service plans.

The facility’s approved Plan of Operation states the facility will provide intensive and structured psychosocial recovery services, including a minimum of four group skills-building activities and/or wellness classes daily. The program schedule provided to LPA notes the 4 scheduled groups, but also includes additional daily meetings and movement groups, totaling approximately seven structured activities per day.

Additionally, the Plan of Operation outlines that staff will support Community Support Systems Development by working individually and in groups with residents to build their support networks. This includes facilitating access to peer-based and self-help services, coordinating weekly outings to community resources (e.g., libraries, AA/NA meetings, Peer Support Centers), and linking residents to essential services such as outpatient mental health and substance use treatment, entitlement benefits (e.g., SSI, Medi-Cal, food stamps), primary care, and housing resources to ensure stable post-discharge living arrangements.

LPA conducted multiple visits and interviews with staff, who reported that while groups are part of the daily schedule, they are often unable to complete all planned sessions due to competing responsibilities such as intakes, discharges, transportation, medication administration, documentation, food service preparation, individual assistance for clients needing social security, identification, housing, prompting clients with activities of daily living (ADLs), hourly rounds, pass off reports, and facility upkeep. Staff also noted that scheduled training opportunities, especially in person, have been cancelled due to insufficient staffing coverage. The schedule provides that often it is one Residential Councilor and one Licensed Vocational Nurse (LVN) who are meeting the direct care staff ratio at this facility.

LPA reviewed group sign-in sheets for two separate periods. From 3/15/25 to 4/15/25, only 45 sign-in sheets were provided and from 6/26/25 to 7/30/25, only 47 sign-in sheets were provided. These sheets include the daily meetings and movement groups. Page 2 - Continued on 9099-C