Facility Evaluation Report, 09/09/2021

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of investigating a complaint (#18-AS-20210902121126) as well as following up on a recent incident which was reported to Community Care Licensing (CCL) regarding alleged physical abuse of a resident (R1) by a staff member (S1). During today's visit, LPA Colvin conducted interviews and reviewed facility records for R1 and S1. Additional investigation for the incident will be taking place on LPA Colvin's part to determine if action by CCL is appropriate.

Additionally, during today's inspection, LPA Colvin observed that a number of staff (6 total) were not associated to the facility. LPA Colvin reviewed staff files for all unassociated staff to confirm background check clearance and to see if a request for association had been submitted to CCL. Below is what LPA Colvin observed:

S1, S2, & S4 are not associated but have active background clearance and transfer request forms in file.

S3 is not associated but have active background clearance. No transfer request in file, but Licensee states has and will email to LPA. S3 started this month and has worked 3 days (9/5, 9/6, & 9/7).

S5 is not associated and needs an exemption approval to work at the facility. An exemption transfer request form was present in S5's file, but has not been approved by the Department. Title 22 Regulations state that if a staff member requires an exemption, it must be granted prior to them being able to work in the facility. S5 has been working in the facility for at least two years without the approved transfer of S5's exemption. Deficiency cited and civil penalties assessed for $100 per day for a maximum of 5 days. Total assessed for S5 is $500.

S6 is not associated but has a background clearance (labeled as active-not working), which expires soon, as S6 has not been associated to any facility since 2019. Additionally, S6 has been working at the facility since 2020 and there is no transfer request form in S6's file. Deficiency cited and civil penalties assessed for $100 per day for a maximum of 5 days. Total assessed for S6 is $500.