Facility Evaluation Report

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Case Management Deficiencies in conjunction with a complaint visit (Complaint Control # 28-AS-20250820145116). The purpose of this visit is to issue deficiencies that were reported by IB Investigator Santana at Investigations Branch. The reason for the Case Management - Deficiencies was explained to Administrator Bryanna Luke.

IB investigation revealed that on 8/07/2025, R2 inappropriately touched and kissed R1’s face, which was seen in facility surveillance footage, actions which were a result of facility neglect/lack of supervision. Prior to this, several staff members had been informed that R2 had made un wanted physical advances toward two other female residents , making them feel uncomfortable. R2 was verbally told to stay away from these residents, but no written warning was issued. On 8/01/2025, a staff member observed R2 also touched R1’s thigh, and the facility’s only response was to tell R2 to stay away from R1, without informing R2's case manager or increasing supervision. After the 8/07 incident, R2 was verbally warned again, but not followed by outside notifications, written warnings, or one-on-one supervision. It is possible that if the above additional measures had been implemented after 8/01/2025, the 8/07/2025 incident could have been prevented. It has been determined that R1’s personal rights were violated as a result of facility’s neglect/lack of supervision.

Deficiencies noted on LIC 809D. Exit interview, a copy of this report along with the appeals rights were provided to Bryanna Luke, Administrator.