Facility Evaluation Report

On 03/14/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Case Management Visit to follow up on an incident report that was submitted to the department. LPA met with Administrator, Demetra Walker, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

During today’s visit, LPA interviewed Clients C1-C3, and reviewed Client C1’s Client Progress Notes, Client Profile, Individual Person-Centered Plan, behaviorist report, tracking Behavior Data Collection for fabrication, and Face Sheet

The department received an incident report from the facility regarding C1 having a behavior where bruising occurred. The incident report stated after the behavior a body check was conducted and bruising was observed. Additionally, the department received an incident report from C1’s day program stating C1 said staff at the facility hit her.

During interviews with Client C1- C3, were asked if staff had hit them, three (3) out of three (3) stated they have not been hit by staff. Additionally, two (2) out of three (3) clients stated a client hits the staff when they are protecting them.

An exit interview was conducted and a copy of this report was provided.