Facility Evaluation Report

Licensing Program Analysts (LPA's) Sabrina Calzada and Kevin Mknelly arrived unannounced to conduct a case management inspection to follow up on an incident report submitted to the Department recently. LPA's met with Kizzy Thorn, Administrator, and stated the reason for the inspection. Also present were staff, Crystal Paulus and DreYonna Baisden. Clients (C1 and C2) were in the common areas and (C3) was in his room at the start of the inspection. Client(C4) was out of the community during the inspection.

During today's inspection, LPA's discussed the incident that occurred on 4/17/24 (approx 3:00pm) between (C1) and (S1). LPA's also reviewed training documentation for all staff, including (S1), and interviewed the Administrator.

The incident that occurred on 4/17/24 appeared to be the result of (S1) failing to follow (C1's) behavior plan which led (C1) to escalate to property abuse of (S1's) vehicle. (S1) intervened during an intervention (S2) was involved in with (C1) and verbally abused and physically pushed (C1) away from (S1's) vehicle. Minimal damage occurred to (S1's) vehicle and (C1) was unharmed. (S2) successfully redirected (C1) to return to the home and (C1) de-escalated with no further incident.

(S1) was sent home immediately following the incident on 4/17/24 and placed on Administrative Leave the following day while an internal investigation was conducted. The Licensee's investigation resulted in (S1's) employment being terminated due to failing to follow facility protocol.

Following the review of documentation and interview, the Department found that (S1) violated (C1's) personal rights by failing to treat them with dignity and respect.

Per California Code of Regulation, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 809-D page.

Exit interview with the Administrator and Regional Director (by phone). Copy of report and appeal rights provided to the Administrator.