Facility Evaluation Report

On 4/13/2023 Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced case management visit regarding an incident that was reported to CCLD on 4/11/2023. LPA met with Maria Baez, Direct Support Professional (DSP) and explained the purpose of the visit. Administrator, Rene Rodriguez, arrived at 12:54PM.

Upon arrival Client 2 (C2) opened the front door and an alarm rang. LPAs stood outside and called out for the staff. Staff S2 came out of bedroom with Client 3 (C3). Staff 2 (S2) was not able to communicate with LPAs being that S2 did not speak English. LPAs asked Staff 3 (S3) did he speak Spanish and he replied "no".

LPA explained to Staff 1 (S1) the reason for the visit when he arrived. LPA obtained and reviewed the following documents: admission agreement and Medication Administration Record (MAR). S1 will email the clients’ roster and staff roster.

LPA reviewed SIR (special incident report) submitted on 4/11/2023, which stated Client 1 (C1) only had six (6) pills left on 4/3/2023. The prescription requires C1 to take two (2) tablets per day. S1 informed the pharmacy that C1 was running low, but the refill needed to be authorized by the doctor. The doctor approved the refill on 4/6/2023, but the pharmacy and surrounding pharmacies were out of stock until 4/10/2023. Administrator and staff observed C1 for any changes of condition, per Administrator there was no changes to C1’s condition.