Complaint Investigation Report

staff members, as well as one (1) client and one (1) witness. LPA also reviewed pertinent documents. The following was then determined:

Staff interviews revealed that the facility has been understaffed. 7 of 7 staff interviewed indicated various times the facility had only one staff on the permanent side. On Friday 06/12/2020, only 1 staff was present on the permanent side. Staff reported this is a consistent problem during the NOC shift and on the weekends. One staff indicated they were consistently 2 staff short during the 2:00 – 10:00PM shift January 2020-March 2020. Staff interview indicated there are staff scheduled to work on the schedule provided to LPA that are out on leave or otherwise unavailable to work. The staff schedule provided to the LPA was compared to a photograph of the schedule posted at the facility and LPA confirmed differences in the schedules. Client interview revealed that Client #1 (C1) frequently does not have a 1:1 staff, particularly at NOC shift. Witness interview revealed that the facility should have 3 staff on the permanent side and one staff on the crisis side during the day and evening shift. NOC shift is required to be 2 staff on the permanent side and one additional on the crisis side. Of the 5 total clients in care, 3 are on a 1:1 and the remaining 2 are a 1:2 staffing ratio. Review of staff schedule for the weeks of 05/31/2020 – 06/06/2020 and 06/07/2020 – 06/13/2020 revealed the LVN scheduled as the fourth staff on Monday, Tuesday, and Friday day shifts. However, QA indicated the nurse is not allowed to be counted in ratio, as they are not a trained caregiver. Schedule review also revealed from 8:00PM – 10:00PM on the following dates, there were only 3 total staff scheduled: 06/03/2020, 06/04/2020, 06/10/2020, and 06/11/2020. Messages reviewed indicated on 03/16/2020 staff were alone for the third weekend in a row, on 03/25/2020 there were two staff working for the five total clients. Email dated 05/07/2020 sent between QA and facility Administration referenced an earlier telephone conversation and indicated “program support hours not being covered” at the facility. Therefore, based on interview and record review, the allegation “insufficient staffing” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided via email.