Facility Evaluation Report

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced case management visit to this facility. The purpose of the visit was to follow up on an incident reports received by Community Care Licensing (CCL) on 06/17/26 and 06/18/26. LPA met with Program Supervisor and explained the reason for the visit. Per incident report dated 06/16/26, S1 was conducting a painting activity in a room with C1 present. During the activity, C1 began hitting S1. Supervisor walked by the activity / music room and observed C1 with their long-sleeve sweater pulled over C1's hands while S1 was holding the sleeves together, restricting C1 movement while continuing the assigned activity. Supervisor informed S1 that this intervention was not permitted and instructed S1 to immediately release C1 engage them in activities and utilize verbal prompts and approved behavioral interventions instead. No further issues were reported following the incident. During the visit, LPA was notified that S1 was placed on suspension pending further investigation. Per incident report dated 06/17/26, C2 became aggressive towards S2. C2 attempted to hit S2. While trying to evade themselves, S2 came out of the room and closed the door keeping participant C2 in the room along with two other clients who were then closed in by her holding the door shut. Program supervisor was already on the route to assist and informed staff S2 to let go of the door, which S2 did. Program supervisor then assisted S2 in de-escalating C2. In both incidents staff confirmed there were no injuries reported to C1,C2 or S1 and S2 as a result of these incidents. No medical treatment was required, and law enforcement was not contacted. It was determined that in both incidents, staff utilized interventions that restricted participant movement and were not approved behavior intervention techniques. These actions violated participant personal rights and facility requirements regarding safe supervision and appropriate behavioral nterventions.

Exit interview conducted and the copy of this report, appeal rights were provided to Program Supervisor