Facility Evaluation Report

On 06/05/2024 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint 31-AS-20240530152840. This Case Management is not related to the original complaint visit. During record reviews LPA observed that a special incident report (SIR) was not reported or sent into Community Care Licensing for an incident that occurred on 5/23/24.

During LPA’s visit, LPA observed there was an SIR missing for 05/23/24 where a client requested medical intervention. LPA interviewed Administrator and Administrator admitted to not reporting incident because they thought that the day program was responsible for reporting since the incident happened at day program. LPA explained that anytime an incident occurs it needs to be reported to CCL within seven (7) days as the facility is responsible for the client and their wellbeing.

Administrator agreed to send CCL SIR to report the incident and will provide Vendor Approved training for all staff on reporting requirements by POC due date.

Citation issued. Appeal rights discussed and provided. Exit interview conducted and a copy of this report was given to Administrator.