Facility Evaluation Report

At approximately 1:50PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Deficiencies visit and met with Executive Director, Susan Edwards, and Health and Wellness Director, Victoria Mozaffari. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA also followed up with the facility regarding incidents that were verbally reported to CCL but not submitted to the Department in a timely manner.

Incident Report 1/SOC-341: CCL received an SOC-341 report on 02/16/2023, and an incident report on 02/17/2023. The incident report states that on 02/14/2023, the facility was informed that Resident 1's (R1) Responsible Party reported a possible injury with bruising. Facility spoke with R1 and Responsible Party about the incident and suspended facility staff while an internal investigation was completed. Facility's internal investigation resulted in the facility conducting all staff training. Facility made all appropriate notifications per regulation.

LPA discussed R1 with Executive Director. Per conversation with Executive Director, Local Law Enforcement came to investigate the incident, and determined that no criminal act had occurred. LPA received copies of the two in-service training sheets that were conducted for staff.

Incident Report 2: CCL received an incident report on 03/20/2023. The report states that on 03/15/2023, Resident 2 (R2) was observed being brought back to the facility by a member of the community. Facility was informed by the individual that R2 was located at a nearby restaurant and that they assisted R2 back to the facility. Facility observed that R2's wander bracelet was removed from their wrist. Facility made all appropriate notifications per regulation.