Facility Evaluation Report

On 05/04/23 at 8:40 AM, Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced

case management visit in conjunction to complaint # 56-AS-20230428084205 and met with DSP, Lameshia Edwards. LPA disclosed the purpose of the inspection and was granted entry into the facility by the DSP.

At 8:55 AM, LPA observed a hole, the size of a basketball, on the hallway wall that is next to the bathroom and another hole with the same size on the wall of (R1) bedroom. DSP stated that the holes were a result of (R1) behavioral episode that occurred on 04/20/23. DSP stated that the Administrator is going to get the walls repaired.

At 9:30 AM, LPA observed staff records and found that (S1) and (S2) do not have background clearance. DSP stated that (S1) has been working since 04/17/23 and (S2) since 02/07/23.

At 10:00 AM, LPA observed through resident records and interview that Special Incident Report (SIR) were not reported to the Regional Office (RO). Administrator stated that DSP was in charge of submitting SIR's. DSP stated that reporting is only sent to IRC and not RO.

An exit interview was conducted and a copy of this report, LIC809D, LIC421BG and appeal rights were provided to the