Facility Evaluation Report

On 3/11/22, Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of conducting a health and safety check on the residents of the facility. LPAs Colvin and Mixon met with Administrators Breanna Bridges and Erica Mata and discussed the purpose of today's visit.

LPAs discussed recent Special Incident Reports (SIRs) with Administrator as well as the plans developed by the facility to ensure continued health and safety of all residents. Resident 1 (R1) has had two recent incidents of drinking hand sanitizer and subsequently needing medical attention. In the facility's plan for action, they stated that staff will have line of sight supervision on R1 at all times that R1 is not in their bedroom or bathroom, and otherwise conduct hourly checks. The facility additionally stated that all hand sanitizer would be removed from the facility to ensure resident safety.

During today's unannounced inspection, LPA Colvin toured the facility and examined all unlocked areas for potential hazardous chemicals. LPA Colvin observed all but one room to be free of chemicals. LPA Colvin was able to enter the staff office, as it was unlocked, and on the bookshelf in the office, LPA Colvin observed a large (over 20 ounces) bottle of hand sanitizer. LPA Colvin pointed the item out to staff along with the fact that the room was not locked when LPAs arrived and LPA Colvin was able to access the hand sanitizer without staff assistance. Additionally, the only staff (S1) present at the time of LPAs arrival was not actively in the staff office, and was cleaning the kitchen area, leaving the unlocked room unsupervised. This is an immediate health and safety risk to R1 as the second incident of R1 drinking hand sanitizer it is believed that R1 obtained it from a locked staff area (staff bathroom). Deficiency cited. LPA Colvin additionally expressed her concern of R1's access to hand sanitizer (and subsequent ingestion of it), as it is outlined in R1's placement paperwork (IPP) that R1 has a history of substance abuse, including ingestion of hand sanitizer.