9. Unannounced Visit: Failure to Provide Safe Environment Copy

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Facility Type: 735 (Adult Residential)

Allegation
Facility staff failed to provide a safe environment for resident in care.

Investigation Findings
LPAs conducted interviews with staff and clients. Based on information gathered and available evidence, it was determined the staff failed to provide a safe environment for residents in care, therefore, the complaint allegation is SUBSTANTIATED, which means the allegation is valid because there is a preponderance of evidence to prove that the violation occurred.

Interviews and documentation revealed facility staff were aware of the history of C2’s sexual misconduct. Interviews revealed staff preferred to house C2 in a room closest to the office to ensure proper supervision however, there was not an available room at the time. C2 was housed in a building farthest from the office and no additional steps were taken to ensure proper supervision was made. Documents show staff conduct hourly checks of clients but this check was not different for C2 than any other client at the facility. Documentation revealed C2 required one-on-one supervision due to their behavior, at the last location C2 resided at, prior to this facility. Interviews with multiple sources revealed C2 continued this behavior and they had incidents with several clients in several locations throughout the facility. In addition, multiple sources informed the LPAs law enforcement was called to the facility regarding one incident. Through interviews and lack of documentation, it appears staff were not even aware law enforcement had been at the facility. An exit interview was conducted where this report, LIC9099D and appeal rights were discussed and provided to the Administrator.

Deficiency Type /
Section Number
DEFICIENCIESPLAN OF CORRECTIONS (POCs)
Type A
05/09/2018
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision: The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: Interviews and documentation revealed facility staff were aware of the history of C2's sexual misconduct.
Interviews revealed staff preferred to house C2 in a room closest to the office to ensure proper supervision however, there was not an available room at the time. C2 was housed in a building farthest from the office and no additional steps were taken to ensure proper supervision was made.
Administrator stated meeting and training with staff to provide appropriate for the needs of the residents in care. Administrator will submit training roster to the Department by POC date.

 

Source
Facility Report

https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=336403045&inx=6

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