Allegation: Staff did not appropriately respond to residents’ mental health needs.

The details of the complaint alleged that facility staff did not tend to (C#1)’s change in mental condition.

On November 5, 2025, at approximately 9:00 AM, Licensing Program Analyst (LPA) Iniguez conducted a records review at the facility and observed documentation related to client (C#1), specifically the Behavioral Observation logs maintained by the staff. The LPA noted that staff consistently documented (C#1)’s behavioral observations twice daily, once during the day and once at night. Each entry included narrative notes detailing (C#1)’s behavior, mood, and interactions throughout the day. This covered engagement with staff, interactions with peers, participation in program activities, and any notable behavioral incidents or changes. The documentation appeared to be individualized, detailed, and signed by the staff responsible, indicating compliance with documentation protocols. This structured approach to behavioral tracking supports the facility’s ability to monitor client progress, identify behavioral trends, and inform individualized care planning. No discrepancies were noted in the documentation reviewed during the visit.

On November 4, 2025, at approximately 10:30 AM, during an interview with the Program Director (A#1), she outlined the procedures that are in place for training staff to recognize and respond to changes in (C#1)’s mental health and behavior. (A#1) explained that the facility conducts a shift exchange and summary at the end of every shift, during which staff discuss any client behaviors that deviate from their baseline. Staff members are trained to observe and document behavioral changes, body language, verbal complaints, client interactions, and any medical or medication-related issues throughout their 8-hour shifts.

Evaluation Report continues LIC 9099-C

On November 4, 2025, at approximately 12:00 PM, during interviews conducted with clients in care (C#1–C#6), (5) out of (6) clients reported that facility staff regularly engage with them regarding their emotional and mental well-being. The clients shared that when they are feeling upset or overwhelmed, facility staff consistently check in with them and provide support through coping exercises.

On November 4, 2025, at approximately 2:00 PM, during interviews with facility staff, (4) out of (4) stated that they are trained to recognize and respond to changes in a client's mental health or behavior. Staff reported that the facility conducts monthly training focused on topics such as behavioral changes, medication management, and monitoring clients' cognitive status. Additionally, (4) out of (4) staff members stated that when learning about incidents or alterations involving a client from a previous shift, particularly those related to mental health or behavior, communication protocols depend on the situation's severity. If the issue is considered severe, staff communicate the change immediately via telephone. If the problem is not severe, it is documented in the client's shift summary, which is completed by either the nurse or Residential Support Staff (RSS).

Allegation: Facility staff are not assisting clients with their dental appointments.

The details of the complaint alleged that facility staff did assist (C#1) with their dental appointment.

Evaluation Report continues LIC 9099-C

On November 4, 2025, at approximately 10:30 AM, during an interview with the Program Director (A#1), she stated that clients in care, including (C#1), are not expected to schedule their own medical appointments. (A#1) explained, “We assist (C#1) and all clients in care with their medical appointments.” When asked about the support available to clients who are unable to coordinate their own care due to mental health symptoms, trauma, or executive dysfunction, (A#1) responded, “If a client cannot attend their medical appointments because of a mental health or trauma condition, the nursing department always provides assistance.”

On November 4, 2025, at approximately 1:00 PM, during interviews with clients in care, (5) out of (6) indicated that they were not expected to schedule their own medical or dental appointments while residing at the facility. Furthermore, (5) out of (6) clients reported that if they were experiencing anxiety, feeling overwhelmed, or had difficulty organizing tasks such as scheduling appointments, they believed that staff would provide the necessary support.

On November 4, 2025, at approximately 12:00 PM, during interviews with facility staff, (4) out of (4) reported that clients are not expected to schedule their own medical or dental appointments. Staff stated that they consistently assist clients with coordinating and attending medical or dental appointments, provided the client is willing to attend. Additionally, (4) out of (4) facility staff confirmed that they provide additional support to clients who may be experiencing anxiety, trauma, or executive functioning challenges. This includes helping clients manage, schedule, and follow through with their healthcare appointments to ensure continuity of care and accessibility of services.

Evaluation Report continues LIC 9099-C

The complaint alleged that facility staff failed to respond in a timely manner to (C#1)’s medication request.

On November 5, 2025, during a records review, LPA Iniguez observed an email from the facility psychiatrist dated October 17, 2025. This email was a response to a message from (C#1), in which they informed the psychiatrist of their intention to take two as-needed (PRN) medications simultaneously: Lunesta 3 mg and Quviviq 50 mg, both prescribed to promote sleep. In the psychiatrist’s response, it was advised that (C#1) take Lunesta alone and avoid combining it with Quviviq due to the potential for compounded sedative effects. However, the psychiatrist also indicated that they would allow the concurrent use of both medications, (C#1) was fully informed about the potential side effects associated with taking the two sleep aids together.

In addition, LPA Iniguez reviewed email correspondence from (C#1) in which they requested the medication Lunesta 3 mg on October 15, 2025. Documentation on the Medication Administration Records (MARs) confirmed that the psychiatrist prescribed Lunesta 3 mg on October 16, 2025, indicating that the request was addressed within one day. Additionally, LPA Iniguez examined email correspondence from (C#1) dated November 3, 2025, in which the client requested a dosage adjustment for Quetiapine (Seroquel). The client specifically asked to reduce the dosage from 100 mg twice daily to 100 mg once daily. A review of the Medication Administration Records (MARs) dated November 4, 2025, confirmed that the dosage was adjusted according to the psychiatrist's orders, indicating that the request was addressed promptly.

On November 4, 2025, at approximately 10:30 AM, during an interview with the program director, (A#1) explained the facility’s current protocol for addressing medication-related concerns that arise between psychiatric appointments, if a client reports an issue related to their medications, facility staff notify the nursing department, which then contacts the prescribing physician to address the concern promptly.

Evaluation Report continues LIC 9099-C

On November 4, 2025, at approximately 1:00 PM, during interviews with clients in care, (5) out of (6) indicated that they had not experienced any delays with their prescribed medications or with access to other medical services while residing at the facility.

On November 4, 2025, at approximately 12:00 PM, during interviews with facility staff, (4) out of (4) reported that in response to how the facility handles medication-related concerns that arise between psychiatric appointments, they reported that the facility has a Licensed Vocational Nurse (LVN) on-site seven days a week and a Registered Nurse (RN) available Monday through Friday. This staffing structure allows for consistent monitoring and timely response to client medication needs. Additionally, (4) out of (4) facility staff stated that when asked about potential improvements to ensure urgent medical needs are addressed more quickly and effectively, staff indicated that no improvements are currently needed. They noted that the facility has a psychiatrist available five days a week, in addition to the nursing staff, which they believe provides sufficient coverage and support for clients requiring urgent medical attention.

Evaluation Report continues LIC 9099-C

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Malia Lindy/Program Director.