Facility Evaluation Report

On 05/10/2024, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to conduct a case management visit based on a recent file review. LPA was greeted by facility supervisor, stated the purpose of the visit and was allowed entry

into the facility. PS called Program Director (PD) who arrived a short time later. Administrator/Area Director also arrived to the facility. During a recent file review, LPA reviewed incident reports for the facility and observed the following.

10/17/23 - report received alleging Staff S1 and Staff S1 had been employing door stoppers to help mitigate behavioral challenges in 2 out of the 4 residents in care. Licensee conducted an internal investigation with findings of unsubstantiated and additional personal rights training was conducted for all staff.

10/21/23 - Resident R1 AWOL'd from the facility and was shadowed. Staff did not lose sight of R1. Program Director (PD) has obtained 1:1 (24 hour) staffing for Resident R1. LPA obtained copy of facility's elopement protocol that includes a 15 minute bed check daily log that is signed by staff on shift. There has been no AWOL incidents reported since this date.

Administrator for facilty is listed as Donte Williams, however, records review and interviews show Administrator is and has not been present in the facility on a daily or weekly basis. Administrator is the Area Director and oversees multiple facilities. Program Director who oversees the facility does not have an Administrator's certificate.

LPA reviewed Needs and service plans for 2 out of 4 residents in care. 4 out of 4 Resident's in care lack hazard awareness/ impulse control and/or may pose a danger to themselves or others. LPA requested facility's Emergency Intervention plan and proof of staff training. There is no plan or training on file.