Complaint Investigation Report

Interviews with staff on 2/6/26 and 2/9/26 confirmed that they have always worked with at least two staff and have never covered a shift alone, but that the option to spit staff to assist clients with appointments is allowed as long as the ratio of 1:6 is kept. Interviews state that this has occurred in the past on other occasions, but no specific dates or time frames could be recalled.

On 2/6/26 LPA contacted the Department of Health Care Services (DHCS) analyst who also oversees regulations that govern the facility and confirmed that DHCS regulations state as a Short-Term Crisis Residential Treatment Program, the facility is required to have "...at least two (2) staff members to be on duty 24 hours a day, seven (7) days per week...There shall be a staffing ratio of at least one (1) full-time equivalent direct service staff for each 1.6 clients served." This is per Section 531(a)(2) of Title 9. While the Title 9 policy does not specifically state the 2 staff must be maintained on the premises, the analyst stated that this is the expectation of the policy to ensure client and staff safety, emergency response, and new client admissions.

Title 22 regulations, Section 81065.5(a)(2), state: "Short Term Crisis Residential Programs shall have at least two direct care staff persons on duty, on the premises, any time clients are in the facility ."

LPA read the Title 22 regulations to the administrator during the 2/6/26 visit. The administrator acknowledged the regulatory requirement for two staff on site at all times and stated that this expectation will be implemented immediately while the LPA continued with the complaint investigation. The administrator further stated that past practice was believed to align with all regulatory requirements and was Telecare Policy. During the final visit, the Administrator demonstrated understanding of the requirement for two staff on site at all times and confirmed that corrective measures will be implemented going forward.

Based on the review, the allegation is substantiated as the facility was not in full compliance with staffing requirements on 2/1/26. While this situation did not present an immediate health or safety risk, and no evidence of repeated or systemic noncompliance was found, the requirement for two staff on the premises was not met. This is considered a technical violation, and no citations are being issued at this time. A Technical Violation is issued for Section 81065.5(a)(2).

Exit interview conducted, and a copy of this report was issued.