Complaint Investigation Report

On 10/09/2023, interview was conducted with administrator and staff at 6:00 p.m.; C1’s file was reviewed at 6:15 p.m. and copies of pertinent documents was obtained. Interview was conducted with a credible witness on 03/11/2024 and information was obtained in support of the allegations.

Regarding allegation “Staff did not meet resident's needs” – Interviews conducted, and records reviewed revealed that C1 has had increasing challenging behaviors since admission (8/1/2020). Administrator reported that C1 has had a history of significant problem behaviors, including physical aggression towards other clients and staff. Case was discussed with a credible witness, and it was confirmed that the behavioral plan for C1 did not show of any specific strategies to prevent, reduce, or mitigate behaviors. The reports were minimal in detail and only included a description of the behaviors without an actual behavioral plan. Neither staff or administrator were able to allude to any specific behavior strategies when questioned. The administrator confirmed that their behaviorist at the time did not provide any consultation or training on any specific strategies for staff to be able to support C1’s behaviors. Based on the information gathered allegation “Staff did not meet resident’s needs” is deemed substantiated at this time.

Regarding allegation “Illegal eviction” – Interviews conducted, and records reviewed revealed that due to C1’s increasing behaviors administrator issued a 3-day eviction notice for C1 on 5/13/2023. Subsequently, the administrator decided to rescind the 3-day notice and issue a 30-day notice to C1. According to administrator C1 presented with behaviors which put others in danger on 5/9/2023. Based on records reviewed there were no needs and service plan that was modified to indicate C1’s needs could not be met, and no actual behavioral plan noted. Based on the information gathered the allegation “Illegal eviction” is deemed substantiated.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report, and appeal rights, were provided.