Facility Evaluation Report

At approximately 1:25PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management Incident visit and met with Staff Member, Zayde Massoud. Administrator, Lakeda Brown-Steward arrived later during visit at approximately 2:05PM. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

LPA reviewed the following reports with Administrator:

Incident Report 1: CCL received an incident report on 12/28/2022. Report states that on 12/25/2022, Client 1 (C1) returned from a family home visit and was observed to have missing medications. Per review of client records, C1 is unable to take medications without supervision. Per conversation with Administrator, C1 was in the care of their family when the medication error occurred.

Incident Report 2: CCL received an incident report on 1/25/2023. Report states that on 1/22/2023, Client 2 (C2), exited the facility and was followed by staff. A member of the community observed C2 fall and contacted Emergency Personnel. Staff met C2 at the hospital. Per review of client records, C2 is unable to leave the facility without supervision. Per conversation with Administrator, C2 has been doing well since their return to the facility.

LPA and Administrator discussed the following:

Incident/Death Reports and Reporting Requirements