Facility Evaluation Report

At 12:15 PM, Licensing Program Analyst (LPA) Huma Rahimi conducted an announced case management visit. LPA met with Administrator and disclosed the reason for the visit.

It was reported by a credible witness that on 03/27/2024, she conducted an annual visit to the above facility and the following deficiencies were noted:

Staff # 1 (S1) hire date 03/01/2021,did not have a required DSP II training on file. LPA conducted a file review of S1 and observed S1 completed the required training on 04/24/2024.

Staff # 2 (S2) hire date 07/01/2023, did have finger print clearance; however, was not associated to work at the above facility. LPA conducted a record review and Licensing Information System (LIS), and observed that S2 is associated since 03/29/2024.

Staff # 3, fingerprint clearance is pending with the department. Administrator informed LPA that S3 is not working at the facility currently. Upon receiving the fingerprint clearance, S3 will be appointed as a staff; and therefore, Administrator allows S3 to take all required training via zoom with all other staff. S3 never comes to the facility to provide care and supervision to clients.

During the credible witness visit on 03/27/2024, it was reported that Staff # 4, and Staff # 5, were not registered on LIC 500 and the facility could not provide files upon request. Based on record S4 was disassociated on 11/10/2023 and S5 was disassociated on 11/15/2023. Therefore, S4 and S5 were not registered on LIC 500 and files were unavailable to the credible witness.