Facility Evaluation Report

On 04/30/25, Licensing Program Analyst (LPA) Villegas conducted a case management visit in response to Special Incident Report submitted to CCLD on 04/17/25 for incident occurring on 4/16/25; regarding Client #1 (C1) and staff #1 (S1). LPA met with Administrator (A1) Monique Weatherspoon as the purpose of today's visit was explained. On 4/30/25 LPA conducted interviews with Administrator (A1), and staff #2-4 (S2-S4). LPA unable to interview Staff #1 (S1), as S1 is no longer employed at the facility. On 4/30/25 LPA Villegas was unable to interview C1 at the time of visit. On 4/30/25 LPA obtained copies of the following for C1, facesheet, physicians report, IPP, medication list, admission agreement, and behavioral report. LPA also obtained copies of the following for S1, personnel record, fingerprint clearance, Criminal record statement, statement acknowledging requirement to report suspected abuse of dependent adults and elders, Crisis prevention intervention (CPI) training verification. LPA obtained copies of the following staff and client roster, body checks documentation dated; 4/15/25, 4/16/25, 4/17/25, and 4/19/25, bowel monitoring chart for April 2025, and consumer notes dated 4/13/24, 4/15/25, 4/16/25, 4/17/25, and 4/19/25, training sign-in sheets; injury/illness prevention training dated 2/28/25, tardiness dated 3/28/25, body checks completed on each shift dated 3/28/25, medication, break log, resident council, fire drill dated 3/28/25, and HCBS the final rule dated 3/28/25.

Due to insufficient information available at this time, the above needs further investigation .

Exit interview conducted and copy of this report was provided.