Facility Evaluation Report

On 04/08/2022 at 12:20 PM Licensing Program Analyst (LPA) Jacob Williams arrived at the facility unannounced to conduct a case management investigation. LPA met with Administrator Juan Andres and explained the purpose of the visit. Prior to initiating the complaint investigation LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

The reason for the visit is a phone call was received on 04/06/2022, concerning an incident that occurred on 04/04/2022 in which it was reported that a staff had headbutted a resident while in care.

LPA reviewed the following documents: Client's Physician's Report. Review of resident's Physicians Report revealed they are on the autism spectrum and is non verbal.

LPA interviewed staff working at time of visit: S2 and S3. Interviews can be found on the attached LIC812.

Administrator to submit SIR to LPA by close of business (4/8).

At this point, there are no deficiencies cited during today's visit. LPA will consult with LPM regarding possible exclusion. An exit interview was conducted, and a copy of the report was emailed to administrator Juan Andres.