Facility Evaluation Report

On 9/27/24 Licensing Program Analyst (LPA) M. Garza completed an unannounced case management visit. LPA met with Robert Perez and was notified the Program Manager, Kelly Wheeler was not available. LPA explained reason for visit and was permitted entry into the facility. A health and safety was completed on clients in care. Clients observed in common areas and in activity rooms.

This case management visit is being conducted for Special Incident Reports received by Community Care Licensing.

Incident #1: C1 did not report to day program for 30 days. Facility attempted to reach father, brother and client without success. A SOC 341 was completed and cross reported to CCL, CVRC, APS and FCSO. FCSO completed a well check on C1. Documentation reviewed and interviews were completed. The facilities policy for reporting was followed. No deficiencies cited for this incident.

Incident #2: C2 takes 3 medications daily at program. On 8/5/24 facility was short staffed and medications were not provided to C2. Facility missed window to provide C2 medications. Trained staff was not at facility to provide medications within the required time frame. Documentation was reviewed and interviews were completed. Deficiency cited for missed medications per Title 22.

Incident #3: C3 came to program with injury to back. RP (mom) reported a fall. C3 reported it was "dad/moms fault". Prior to this injury C3 was given extra support and medications adjusted. Documentation was reviewed and interviews were completed. Facility cross reported to appropriate agencies. No deficiencies cited for this incident.