Facility Evaluation Report

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20260122125743. LPA met with the administrator and explained the reason for the visit.

Administrator did not submit a Special Incident Report (SIR) to Community Care Licensing (CCL) regrading property damage involving Client #1 (C1) and Client #2 (C2). On separate occurrences C1 and C2 damaged their beds. According to staff interviewed, C2 has a history of behavior related to damaging their personal items and items in their room. The facility ordered new beds for C1 and C2. Interview with the administrator and staff also revealed the administrator was made aware of medication discrepancies but did not report it to CCL.

LPA's review of medication records revealed the facility did not have proper documentation for a PRN or as needed medication that was missing from C1's bubble-pack in the month on January. According to C1's PRN authorization C1 is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly which would require the facility to contact C1's physician's which did not happen on 01/05/26 and instead the administrator provided the approval without contacting the client's physician prior to the dose. According to the administrator they will reach out to C1's physician because C1 is able to describe their symptoms.

Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report provided.