Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a Special Incident Report (SIR) submitted to the Community Care Licensing Office on 11/06/23. LPA was greeted and met by Elsie Strain at the front door. LPA introduced self and stated purpose of the visit.

On 10/27/23, IRC received a call from client's family stating that client had pulled a knife on the staff.

During today's visit, LPA met with Staff to discuss the incident and surrounding events. LPA did a health and safety check, interviewed clients and staff and reviewed records. During record review, it was discovered that the facility did not report the incident to the regional office.

Deficiency was issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and then provided to Licensee, Arvin Sarroca who later arrived.