Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted a Case Management - Other visit. LPA was greeted and allowed entry into the facility by Nick Fierro, Administrator. LPA stated the purpose of the visit was to follow up on the incident reports received on 10/04, 10/07, & 10/08 2024.

During today's visit, LPA briefly toured the facility, requested records, and conducted interviews. LPA Holmes is conducting a health and safety check regarding Client 1 (C1). LPA and Administrator reviewed the incident reports together. C1 has been having an uninvited guest at the facility. This guest has been in their room and have left once staff asked them to leave, although they come back on each shift, when there is a new staff. Facility staff has a concern that the visitor is not safe to be around the other clients, staff and C1. C1 has been violating the facility rules and has been given several notices (at least 2). Interviews with staff have revealed they do not feel safe when that visitor comes to the facility and has even more concern for the staff of the opposite sex of the visitor. Interviews revealed they have added more rounds to their shifts and are making sure the uninvited guest is not in C1s room or around the facility and has an increase in staff. There was a private security officer that was hired for two nights to keep the unwanted visitor out of the facility.

No deficiencies were seen or issued during today's visit.

An exit interview was conducted with Administrator and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 03/22), were provided to the Administrator at the conclusion of the visit.