Facility Evaluation Report

On 01/30/2026, Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management – Deficiencies visit in conjunction with complaint control #31-AS-20250131102020. LPA met with the administrator and explained the purpose of the visit.

During the complaint investigation two (2) staff members reported witnessing violations of personal rights by Staff#1 (S1). One staff member stated they observed S1 handle Client #1 (C1) in a rough manner, while another staff member reported witnessing S1 press their elbows into C1’s back and antagonize clients to provoke arguments among them. Both staff members acknowledged they did not report these incidents to the administrator or licensee. One staff member stated they didn't bring it up because they were never asked about it, and the other reported they did not realize the restraint or hold used was inconsistent with CPI training until receiving additional CPI training.

Deficiency cited refer to LIC809-D. Appeal rights provided. Copy of report provided.