Facility Evaluation Report

Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced case management visit to this facility regarding an incident report received by CCL Regional Office. LPA met with day program manager Marcia Ramos who was informed of the reason for today's visit.

On 6/5/2023, CCL Regional Office received an incident report that stated violation of client (C1) rights. The report noted that Staff 1 (S1) found C1 with briefs that were not included in C1's physician's order. S1 informed Staff 2 (S2) that C1's briefs should be removed and S2 stated that they did not want C1 to have an accident on their way home.

During today's visit, it was discovered that S2 had been placed on unpaid administrative leave. Records reviewed show that S2 received training on abuse reporting and clients' rights in the first quarter of 2023. Staff interviews revealed that there was cause for C1 needing briefs, however this was a temporary change in condition from the last quarter of 2022. C1 resides in a facility that requires a higher level of care.

No deficiencies were observed during today's visit. A technical advisory was issued to remind staff of the importance of maintaining an accurate record of the client's needs and services however temporary. A copy of this report was reviewed with and provided to Marcia Ramos at the conclusion of this visit.