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During today’s visit, starting at 10:33 a.m. LPA and staff conducted a physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations, at 10:50 a.m. conducted an in-person interview with the Administrator, at 11:00 conducted a file review, and obtained copies of pertinent documents relevant to the investigation.
On the allegation Facility did not keep current and accurate records, it is the concern of the Reporting Party (RP) that the treatment/ rehabilitation plan for Client #1(C1) did not contain documented evidence of ongoing review of progress towards reaching established goals, was not completed at least weekly, the treatment/ rehabilitation plan for C1 and Client #2 (C2) did not contain documented evidence of methods to evaluate achievement of goals, and the discharge summary for Client #3 (C3) did not contain documented evidence of an outline of goals accomplished and referral follow-up plans. To investigate this complaint, LPA conducted a file review for C1,C2,and C3, and reviewed the California Department of Health Care Services (DHCS) annual review dated 05/14/2025. File review revealed that on 05/14/2025 the treatment/ rehabilitation plan for C1 did not contain documented evidence of ongoing review of progress towards reaching established goals. The treatment plan (TP) in C1’s charts did not have updates. There was only one TP. The TP needs to be current and accurate signed by both staff and client. There was only one TP for Client #1 who arrived 4/28/25 and had the initial TP done on 4/29/25 but no updates after that date. The treatment/ rehabilitation plan for C1 and C2 did not contain documented evidence of methods to evaluate achievement of goals. The objective or plan was not measurable with a method to evaluate the goals. The discharge summary for C3 did not contain documented evidence of an outline of goals accomplished and referral follow-up plans. Portions were left blank for referral and follow up information which poses/posed a potential health, safety or personal rights risk to persons in care. On todays visit the TP for C1 was updated with a weekly review of what was done the previous week and is current. TP for C1 and C2 contained updated documented evidence of methods to evaluate achievement of goals. TP for C3 contained documented evidence of an outline of goals accomplished and referral follow-up plans. Based on information obtained, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Facility did not keep current and accurate records is deemed substantiated at this time.
Report continued on LIC 9099-C PAGE 3... |
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On the allegation Staff do not have appropriate training, it is the concern of the Reporting Party (RP) that records for Staff #1-8 did not contain documented evidence that the employees had one (1) year of full-time experience, or its part-time equivalent and Staff #9-12 did not contain documented evidence of at least 20 hours of in-service training per year. To investigate this complaint, LPA conducted a file review for Staff #1-12 and reviewed the California Department of Health Care Services (DHCS) annual review dated 05/14/2025.
File review revealed that on 05/14/2025 Eight (8) personnel records for Staff #1-8 did not contain documented evidence that the employees had one (1) year of full-time experience, or its part-time equivalent, working in a program serving persons with mental disabilities or a documented plan of supervision. Staff had an agreement for a Plan of Supervision but was missing the sign-in sheets that showed evidence that the supervision was occurring. Sign in had one form signed with everyone that was missing dates and start and end times. The facility was unable to provide documented evidence that they were providing and documenting at least twenty (20) hours of in-service training for employees. Four (4) personnel records for Staff # 9-12 did not contain documented evidence of at least 20 hours of in-service training per year for the employee to ensure the ongoing qualifications of the individual to perform the job which poses/posed a potential health, safety or personal rights risk to persons in care. On todays visit the staff records were organized with individual staff sign in sheets with the date, start time, end time, duration, topic covered, presenter name, staff name, signed by staff and presenter. The facility conducted training with all staff documenting the training individually by staff on a sign in sheet for each time they meet with staff, what was discussed during the plan of supervision along with when the 20 hours of training and orientation was conducted. Based on information obtained, file review and a credible witness there is sufficient evidence to support the allegation occurred. Therefore, the allegation of Staff do not have appropriate training is deemed substantiated at this time.
The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.
Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/18/2025
Section Cited
CCR
81070(a) | 1
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7 | 81070(a) Client Records : The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. This requirement was not met as evidenced by: | 1
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7 | POC cleared on site.
During today’s visit, the treatment plan (TP) for C1 was updated with a current weekly review of the prior week’s activities. The TPs for both C1 and C2 included documented, updated methods for evaluating goal achievement. |
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14 | Based on information obtained, file review and a credible witness Client #1 -3 did not have complete, and current records which poses/posed a potential health, safety or personal rights risk to persons in care. | 8
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14 | Additionally, the TP for C3 contained evidence outlining completed goals and referral follow-up plans. |
Type B
06/18/2025
Section Cited
CCR
81065(n) | 1
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7 | 81065 (n) Personnel Requirements : All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i).This requirement was not met as evidenced by: | 1
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7 | POC cleared on site.
During today’s visit, staff records detailed individual sign-in sheets capturing key training session information. Docmentation of staff training and supervision meetings thoroughly, including training content, presenter details, and completion of required orientation and |
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14 | Based on information obtained, file review and a credible witness Staff #1-8 did not contain... employees had one (1) year of full-time experience...Staff #9-12 did not ... least 20 hours of in-service training per year which poses/posed a potential health, safety or personal rights risk to persons in care. | 8
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14 | training hours. |