Complaint Investigation Report

Regarding allegation, Licensee does not ensure that staff are adequately trained: Information was received that staff lack training in de-escalation techniques. LPA reviewed a total of five (5) staff files and conducted interviews with staff. Records reviewed and interviews conducted revealed that staff complete training prior to hiring and are provided with ongoing training annually. SD explained that the corporate has a tracking system for staff training; training is through Relias; staff due for training complete the required training on a flow basis. Staff interviewed confirmed receiving training in challenging behaviors, de-escalation techniques and other support techniques upon hire and annually. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Licensee does not ensure that staff are adequately trained” is deemed Unsubstantiated at this time.

Regarding allegations, Staff do not adequately supervise clients in care and Licensee does not adhere to staff-client ratio requirements. Information was received that clients are often unsupervised; clients regularly eat without staff supervision, posing a choking hazard. Additional information provided was that the program is critically understaffed; Lead Instructors / LVNs inappropriately counted toward the staff-to-client ratio. Investigation consist of interviews with staff and randomly selected clients. In addition LPA reviewed that facility staffing assignments for 8/2025-9/2025. Interview with staff and randomly selected clients able to communicate revealed that staffing is sufficient and not understaffed. Client expressed being satisfied with the program and staff. LPA reviewed the facility schedules and staffing assignments. Records review revealed there are 30 DSP staff, 2 management staff and 4 nurses; total clients served is 51, with 44 clients on 3:1 client to staff ratio, 7 clients served 1:1 by the program and 2 clients served 1:1 by outside agency. LPA observed the facility to be following their client to staff ratio during unannounced visit conducted by LPA on 08/13/2025, 09/05/2025 and 11/20/2025. Regarding clients regularly eating without supervision, staff denied the allegation and reported that there is always a staff present while clients are eating. Clients interviewed confirmed that there is always staff present.

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations “Staff do not adequately supervise clients in care and Licensee does not adhere to staff-client ratio requirements” is deemed Unsubstantiated at this time. (Continue to LIC9099c)