Facility Evaluation Report

On 11/17/23 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit regarding a self reported incident that occurred on 11/9/23. LPA introduced herself and explained the reason for the visit. LPA met with Administrator (AD) Christine Lawrence.

Self report indicated there was an incident of client on client. Administrator stated they do not believe this was a form of abuse but rather an unusual behavior for one of the clients. Administrator stated the client who displayed aggression during the incident does not have a history of aggressive behavior towards other individuals in the program.

LPA interviewed staff who verified this is unusual behavior for the clients involved in the incident. Interviewed staff stated their training's have prepared them for incidents that may arise with behaviors, but this behavior was not avoidable since there was no indication of behavior escalating and it was an unusual behavior.

Administrator stated the individuals were separated, meetings were held with the individuals and their responsible parties, the police department was contacted but only an event number was provided. Administrator stated there have been no other incidents of aggression.

LPA toured the inside of the facility to verify there was no immediate dangers.

LPA collected copies of IPPs for clients listed on the incident report, staff schedule for the date of incident, verification of current CPI training, and procedures on reporting.

At this time LPA did not find any deficiencies and no citations were issued.

Exit interview was conducted and a copy of this report LIC809 was provided to Administrator Christine.