Complaint Investigation Report

reviewed pertinent documents. The following was then determined:

Regarding the allegation that “staff did not provide one on one supervision to resident,” record review revealed that Client 1 (C1) requires 1:1 supervision at all times. During the time of the allegation, staff schedule did show that there was a 1:1 staff assigned to C1. Interview revealed that there was an incident involving Client #2 (C2) and during the incident, C1’s 1:1 staff went to assist with C2. Staff and Administrator stated that C1 was left outside unsupervised during the incident. Prior to the incident, C1 had also been unsupervised while C1’s 1:1 staff was inside cooking and C1 was outside smoking. During today’s visit, when LPA and QA arrived, C1 was observed to be outside with no 1:1 staff within line of sight. LPA and QA observed a swing outside in the shade where C1 chooses to spend time outside is not near a window, nor is it visible from the interior of the facility. Based on record review and interview, the allegation that “staff did not provide one on one supervision to resident” is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview was conducted with Acting Administrator Maria Drummond. A copy of the report and appeal rights were provided via email.