Facility Evaluation Report

Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240926110610. LPA met with Staff, Kevin Johnson.

During today's visit, LPA conducted interviews with clients, staff, and did a walk-through of the facility. LPA found the following issues:

LPA was unable to access facility records since Administrator did not provide access to the staff present.

Administrator did not report to the Regional Office of an incident that threatened the safety of the clients.

Administrator did not report within 7 days, the occurrence of a separate incident.

Knife was previously accessible to clients.

These pose an immediate and potential health and safety risk to clients in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report LIC809, LIC809D, and appeal rights were discussed with and provided to Staff, Kevin Johnson.