Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown met with Licensee/Administrator Diana Rojas at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 11/22/2022 at 8:30 AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

Interviews with staffs and client during the facility visit last 03/23/2022 at 12:00 PM indicated that Staff 4 (S4) used Crisis Prevention Intervention (CPI) to Client 1 (C1) last 02/28/2022 and 03/02/2022 due to C1’s aggressive behaviors that presents immediate danger to self and to others. However, per documents review, LPA Brown observed no debriefing occurred within 24 hours of the used of CPI last 02/28/2022 and 03/02/2022. LPA Brown explained to Administrator Rojas the importance of debriefing. In addition, interview with Staff 1 (S1) confirmed that the facility did not conduct debriefing regarding the incident last 02/28/2022 and 03/02/2022. Also, S1 reported during the interview of not being aware of debriefing procedure. LPA Brown will be issuing a deficiency for this issue as no documentation of debriefing was observed during the visit and this pose immediate risk to clients in care.

LPA Brown informed Administrator Rojas that debriefing includes involved client (C1), staff involved (S4) and a supervisor (Administrator) and if a client requested their authorized representative. Moreover, LPA Brown emphasized to Administrator Rojas that debriefing provides opportunity for both staff and client to discuss the circumstances resulting in the use of seclusion or restraint and strategies to be used by staff, client or others that could prevent future use and Administrator Rojas expressed understanding.