Complaint Investigation Report

On the allegation “ Staff does not have adequate training”; it is the concern of the reporting party that staff was not trained on how to remove Client 1 (C1) from certain situations once it has been identified that C1 has aggressive behavior. It was reported that while on a community outing with Staff 1 (S1), C1 pushed a shopping cart into a community member while waiting in a checkout line. While S1 was checking on the community member’s well-being and providing management’s contact information, C1 reportedly struck a second community member who was also in line. To investigate the allegation the LPA conducted file review and staff interviews.

File review revealed that the facility’s program design mandates the new employee orientation includes training on Individual Program Plans (IPP) per Welfare and Institutions Code 4646. However, during interviews four (4) out of five (5) staff that provided direct support to clients, including Staff 1, stated that they do not receive training specific to the needs of the individual clients they support. Staff further revealed that they are provided with Crisis Prevention Institute (CPI) training, but it is not specific to any one client. Additionally, staff indicated that it is suggested staff go through the client’s binder to get their basic information, and they can review the client’s needs and service plan. Staff interviews also revealed that the only training specific to the clients they receive is if a client is using a medical device such as G-tube, not behavioral training. Furthermore, interview with S1 revealed that their experience as a 1:1 provider has taught them to remain hyper-vigilant by observing a client’s gaze, distractions, hand movements, and body shifts, however they were not given training specific to C1. Additionally, S1 did not have any training records on file specific to individual client needs and/or IPPs. Based on staff interview and file review, there is sufficient evidence to support the allegation and that a violation occurred; therefore, the above allegation is deemed Substantiated at this time.

The following deficiency was cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview held, appeal rights and report copy provided.