Facility Evaluation Report

On 12/14/2023 at 10:45am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit. This is a follow-up visit pertaining to a self reported incident regarding a client being injured by a staff person on April 9,2022.

On April 9, 2022, Client 1 (C1) was stabbed in the head, back and arm by Staff 3 (S3). LPA met with Carol Duenas, Licensee, and explained the reason for the visit.

The Department obtained and reviewed records from the facility, Antioch Police Department (APD), John Muir Medical Center, but was not limited to interviews with current staff and witnesses.

Client 1 (C1) was taken to John Muir Medical Center and treated with 33 stitches to close four (4) stab wounds. C1 was released and returned to the facility the same day of the incident.

Based on the investigation, including self reported incident report, C1 sustained injuries from S3. S3 was a new employee and was not properly trained to redirect clients with aggressive and /or violent behaviors. Based on staff interviews, S3 was being shadowed by another employee when the incident occurred. C1 has a history of violent behavior towards staff. The licensee did not have a personnel record for S3 and S3 was not fingerprint cleared. During the case management visit on September 15, 2022, licensee was cited for these 2 violations. The Department issued an immediate exclusion notice to S3 and delivered it to the facility on August 17,2022.