Facility Evaluation Report

Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced case management-deficiency visit. The LPA met with Lito Vitug, Executive Director (ED) and explained the reason for the visit . During the complaint investigation of complaint #29-AS-20230821084701, the following deficiencies were observed:

During an interview conducted on 08/24/2023 by the Department, the Administrator stated that R1 had recently begun smoking marijuana and drinking alcohol along with taking their regular medication. The Administrator stated they have noticed mild cognitive impairment in R1 since then. There was no Reappraisal done for R1’s change in condition. The Individual Service Plan (ISP) the facility submitted to the Department during the complaint investigation was dated 12/22/2022.

The Unusual Incident Report submitted by the facility, dated 08/15/2023, did not reflect that R1 had made an allegation against S1 for sexual abuse. The Executive Director, Facility Manager, and the Administrator were made aware of the allegations on 08/15/2023 and suspended S1 during the complaint investigation. The licensee did not submit a Report of Suspected Dependent Adult/Elder Abuse (SOC341) form.

Citations issued, exit interview was conducted and a copy of the report and Appeal Rights were issued..