Facility Evaluation Report

LPA Melissa Spaeth and LPA Gina Saucedo conducted an unannounced visit. Upon arrival, LPAs were greeted by a client (C1) who stated Administrator had left the facility for a few minutes but would be returning. C1 stated the live-in staff was asleep in the staff room. LPA called Administrator at 9:30 am and left a message. C1 stated was a new client and moved in about 9/01/2023 At 9:35 am, C1 invited LPAs to enter the facility and LPA Spaeth knocked at the staff room's door. However, no one responded to the knock and LPAs did not know if the live in staff was at the facility. LPAs also knocked at the exterior door that led to the staff room; however, no one responded.

The Administrator arrived at 10:20 am. LPA Spaeth stated the purpose of the visit was to conduct a case management tour and LPAs were accompanied by the Administrator at 10:25 am for the tour. LPA Spaeth asked Administrator the move-in date of C1. Administrator stated C1 was a hired construction worker to assist with the remodeling of bathroom #2. LPA stated upon arrival, C1 confirmed was a new client as of 9/01/2023. LPA asked Administrator to confirm. Administrator stated C1 was actually a resident but was assisting Administrator with the remolding process.

LPA asked for client’s file but Administrator did not have the file at the facilty. LPA also stated the client should not be assisting with the remodeling process since C1 is a resident. LPA also stated based upon Title 22 regulations, client files must be available for LPAs review. The Administrator failed to provide the documentation to the LPAs during the visit.

Also, the Administrator asked C1 to leave the facility during LPAs’ visit and C1 left at 10:45 am. LPAs asked if Administrator knew where client was going but Administrator stated did not know.