Facility Evaluation Report

Licensing Program Analysts (LPA's ) Stevenson and Contreras, Licensing Program Manager (LPM) Mota conducted an unannounced case management inspection and met with Yvette Morgan. The purpose of this case management inspection was to follow up on self reported incident submitted to Community Care Licensing (CCL) on 01/30/2024. LPM and LPAs conducted a tour of the facility and reviewed records.

On 01/30/25, it was reported to CCL that on 01/24/25 staff (S1) observed staff (S2) aggressively place a cup of hot water in front of non-verbal client (C1) who was yelling and told to "stop" When asked S2 stated, "this is what we do to scare C1:sometimes we will tell C1 they will shower"

On 01/24/25, facility initiated an internal investigation of the incident and found that 3 staff (S2, S3, S4) were involved in the incident which involved using hot water and cold showers as a form of behavior control of C1. It was discovered during the investigation that this treatment of C1 has been going on for "a while". (S2, S3, S4) were immediately suspended and on 02/05/2025 CCL was informed (S2, S3, S4) were terminated effective 02/03/25, per internal investigation

CCL confirmed facility staff reported appropriately to CCL, Novato Police Department (NPD), Golden Gate Regional Center (GGRC), and Ombudsman. In addition, all staff have been re-trained on reporting requirements, SIR training to be conducted by GGRC on 02/10/25, mandatory reporting training.

C1 was seen by their psychiatrist, on 02/04/25 to identify if C1 sustained any need for treatment due to the incidents

Yvette Morgan-Program Operations Manager was advised to ensure that S2,S3,S4 were removed from Guardian roster.

No deficiency cited during today's inspection.