Facility Evaluation Report

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for a complaint and during the investigation LPA Allen was made aware that staff did not meet the required reporting requirements.

During LPA Allen's visit it was determined that the facility staff did not provide community care licensing division with the required document for reporting incidents within the required time frame of seven days following the occurrence of an incident. The interview with Pat Dunca stated that the incident regarding C1 leaving the day program with an unauthorized representative was not reported to community care licensing.

LPA made Pat aware that the facility will be cited regarding reporting requirements and the licensee has agreed to provide training to all staff members on reporting requirements.

A copy of this report LIC809 and LIC809-D was discussed and provided to Pat Dunca at the conclusion of the visit.