Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to provide deficiencies revealed during a complaint investigation. LPA met with Luther Waters Administrator and explained the reason for the visit.

During complaint # 28-AS-2023032911250 investigation, Administrator stated Client #2 (C2) had been showing inappropriate behaviors towards client #1(C1) for at least six months. On 2/9/23 C2 touched C1’s chest and rear end and on 3/21/23 C2 touched C1’s chest area. This was reported to the department via fax. During the investigation another client (C3) living at the facility stated to have experience C2’s touching as well. Both clients stated to have requested C2 to stop such behavior as it was unwanted by them. Facility has provided staff supervision and redirected C2’s behavior each time. However, the facility did not have a written plan in place to prevent the behavior from continuing. Last Triennial Individual Plan was conducted on 8/12/19 and reviewed by LPA. During the complaint investigation visit Triennial Individual Plan dated 8/12/19 was the most current service plan on file for C2.

Deficiencies have been noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.