Facility Evaluation Report

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management -Deficiency visit. LPA was greeted and allowed entry into the facility and met with Administrator, Yuri Vega.

On 11/15/23, LPA observed Client #1(C1) sitting in their room in a large chair propped up against their bedroom door, which did not appear unusual. C1 also has another door to access their bedroom that leads from a bathroom from a common area. There didn’t seem to be any concerns as C1 chose to sit in that chair instead of the common area. Today, 11/17/23 LPA observed the large chair blocking the bedroom entrance again and the door was also locked from the inside. Staff interviews revealed the large chair was blocking the door and locked for C1’s safety. C1 is unable to unlock the door due to their mental capacity. There’s another client, Client #2 (C2) who will run up to C1’s bedroom door and try to enter. C2 has a known behavior of biting and a medical condition that affects their auditory and sensory abilities. When C2 hears C1 making noises in their room, it can trigger C2 to want to attack C1 by biting them. Therefore, staff thought if they blocked the door and locked it would allow for safety of C1. Staff were made aware they cannot block the door or lock it. The facility staff are required to meet the needs of clients and ensure compatibility. The licensee was aware of C2’s biting behaviors prior to accepting C2 into care. The facility staff are capable of supervising the clients. However, the licensee did not ensure staff are equipped to handle C2’s behaviors, as C1’s personal rights were violated, while trying to protect C1. The facility has rectified the situation by relocating C1 to another bedroom away from C2. Also, the facility is in the process of hiring additional staff equipped to handle the behaviors in the home.

Based on observations and interviews a deficiency is being issued today for barricading and locking the door, instead of ensuring staff are equipped with handling certain behaviors accepted by the facility. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Yuri Vega whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Client #1 and Client #2].