Complaint Investigation Report

Upon review of the staff schedule for the week of 7/25/2021, the schedule states that there should be four (4) staff members present on 7/29/21. LPA observed a total of three (3) staff members present at the time of visit at 12:45 p.m., two (2) in the permanent side and one (1) in the crisis side. Interview with staff #1 (S1) revealed that there was a one (1) hour and a half gap on the morning of 7/29/21, and that they only had 2 staff members present. LPA reviewed the day schedule for 7/29/21 and observed that there were three (3) staff members scheduled to come in at 6:00 a.m. and another staff member at 7:30 a.m. LPA received the Employee Pay Summary Report, which identifies the start and end times of a staff members’ shift for the entire month of July 2021. Upon further review of the Employee Pay Summary Report, it was revealed that on 7/3/2021 during the entire night shift (10:00 p.m. – 6:00 a.m.), there were only two (2) staff members present. On 7/5/2021 during the morning shift (6:00 a.m.- 2:00 p.m.) there was one (1) staff member present starting at 6:00 a.m. with the second staff member arriving to the facility at 7:20 a.m. and a third staff member arriving at 9:50 a.m. On 7/25/2021 there were two (2) staff present starting at 6:00 a.m. with a third staff member arriving at 7:20 a.m. Later that evening, there were two (2) staff members present during the night shift (10:00 p.m. – 6:00 a.m.) On 7/26/2021 there were two (2) staff members present during the morning shift (6:00 a.m. – 2:00 p.m.) with a third staff member arriving at 1:40 p.m. Later that evening, there were two (2) staff members present, as well as on 7/28/202, there were also only two (2) staff members present during the night shift. LPA interviewed QA Aced-Arnett starting at approximately 3:15 p.m. on 7/29/2021, who confirmed that the minimum staff present at all times should be no less than four (4); three (3) staff on the permanent side and one (1) staff on the crisis side of the facility. It was also revealed there is no limit to the amount of hours staff are allowed to work in regards to funding from Tri-Counties Regional Center (TCRC), as long as the minimum staffing ratio is met at all times. On 7/29/2021, LPA reviewed residents’ Individual Program Plans (IPPs). Upon review of the IPPs, it was revealed that client#1 (C1) requires 1:1 staffing. C2’s IPP, dated 1/29/2020, was also reviewed and stated C2 is “attached to a 1:1 support and requires line of sight supervision at all times.” Additional information was obtained from People’s Care District Manager via email dated 9/13/2021, stating the facility, at any point in time, should have four (4) staff in place per shift.

Based on observation, review of files, and interviews, the department has sufficient evidence to determine that the allegation of facility minimum staffing requirements are not being met. Therefore, the above allegation is SUBSTANTIATED at this time.

The following deficiencies were 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.