During interviews staff informed that while the facility continued to have staff deficits, significant efforts had been made to meet required staffing levels including continuous hiring, having staff from a sister facility travel to the facility when that facility was overstaffed, having supervisors and management serve as ratio staff when in deficit, and utilizing local Home Care Organizations (HCOs) with staff trained for the needs of the population. Staff informed that call outs were due to a variety of reasons, including staff being on worker's compensation from client injuries, burnout due to the nature of the population served, and personal reasons. Staff informed that a particular client in the home had significantly high needs which challenged the facility's ability to balance the needs of the other clients in the home.

Outside source interview with a Home Care Organization (HCO) confirmed that the facility had utilized their services to help meet the staffing requirements. A placement agency familiar with the facility expressed concern regarding the facility's staffing issues and ability to meet the needs of the clients.

Records review corroborated the allegation, as the facility had submitted numerous incident reports pertaining to staff deficits since 2024. The facility additionally notified the Department via phone on 11/18/2024, 12/02/2024, 05/07/2025, 07/14/2025, 09/15/2025, and 10/15/2025 regarding staffing deficits. The facility's attendance policy emphasized the importance of punctuality and reliability for shifts worked. The document stated, "Our commitment to the highest possible standards of care, and our compliance with the codes and regulations that govern our operations, are at risk if you are late for work. If you are repeatedly late or absent, you put the people we support at risk."

Regarding medication administration, it was alleged that an injection was administered to Client 2 (C2) after C2 showed attempts to refuse the medication. An internal investigation was conducted by the facility regarding the administration in question. The investigation revealed that five (5) staff members directly witnessed C2's arm being held down by a non-staff outside party familiar to C2 while a facility staff administered the injection. The involved staff and outside party confirmed that C2's arm was held down while the medication was administered. (Continued on LIC9099 p.3)

The witnesses informed that C2 stated "No" upon attempts to receive the medication and resisted the administration, however it was still administered. The internal investigation identified that C2 should have been provided breaks and allowed to proceed at their own pace during the administration.

Attempts were made to speak with C2 during facility visits, however C2 was unable to be interviewed.

An attempt was made to interview the outside party involved in the incident, however contact attempt was not successful.

Records review corroborated the allegation, as the Licensee self-reported the incident to the Department and provided the internal investigation report. Additional records included an internal email from a staff member who witnessed C2 being given the medication while attempting to refuse, and an internal reporting note that stated C2 protested while receiving the medication in question.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violations occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with Administrator Natasha Stutzman via phone. An exit interview was conducted with Lead RBT Jaylen Lange and Administrator Natasha Stutzman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Review of facility records showed that the facility submitted an incident report to the Department on 10/25/2024 regarding the egress door not latching, causing the alarm to sound. The incident report informed that a work order was submitted and it was scheduled to be fixed on 10/31/2024. A Maintenance Request Form, dated 10/21/2024 showed that a high priority repair request was submitted for the egress alarm. An email dated 10/25/2024 showed that the maintenance request was submitted. Shift reports dated 10/25/204, 10/28/2024, and 10/29/2024 included staff statements regarding the delayed egress not working.

During two unannounced facility visits, LPAs directly observed the egress gate in question. On 11/05/2024, the door was observed to not immediately latch and was observed to be secured with black electrical tape, however, the required time had not elapsed for the lock to engage before testing. On 5/14/2026, the door was observed to latch properly after approximately 2-seconds, without opening again.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Jaylen Lange and Administrator Natasha Stutzman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.