Facility Evaluation Report

On 05/06/25 Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Carolina Mateo for a case management visit. The purpose of the case management visit is to address deficiencies observed during the course of investigation for complaint # 31-AS-20250411092910. The deficiencies were not alleged but are related to the complaint.

LPA Casillas was investigating the above referenced complaint when LPA observed that Staff #1 (S1) had a “Pending” status on their fingerprint clearance. S1 has been providing direct care and supervision to clients since 08/22/24 without being fingerprint cleared to work in the facility. LPA explained to Administrator that this is an immediate civil penalty, and that staff needs to be removed and not provide care and supervision until properly being fingerprint cleared. Administrator states that S1 works as needed but that they would be removed from the schedule immediately.

LPA also observed during staff file review that Staff #2 (S2) did not have a health clearance to include tuberculosis (TB) testing prior to 03/20/25. LPA observed that S2 was hired on 01/20/25 but had not completed a health clearance nor had S2 provided a TB test within the first seven (7) days of being hired or a valid test performed not more than one year prior. LPA explained to Administrator that all staff need to have a health screening and a valid TB test in order to provide direct care and supervision to clients. Administrator stated that S2 is no longer employed with the facility since S1 resigned on 03/31/25. LPA informed Administrator that even though S2 was no longer employed, S2 provided care and supervision to clients during S2’s tenure at the facility, therefore a citation would be issued. Please see LIC809-D and LIC421-BG

Citations issued. Appeals rights discussed and provided. Exit interview conducted and a copy of this report given to Administrator.