Facility Evaluation Report

On 3/5/2025 at 2:00pm, Licensing Program Analysts (LPAs) Michael Bilger and Noel Wolf Petersen arrived unannounced to conduct a case management visit related to complaint # 27-AS-20241223102104. LPA met with Administrator Ada Osuka and explained the purpose of the visit. LPA conducted interview with three staff members and one resident in care. LPA also reviewed facility file documentation including staff schedule, individual program plans (IPPs) for resident1 (R1) and R2, incident reports, needs and services plans, and physician’s reports. LPA also conducted a facility observation on 3-5-25 and reviewed a police report associated with the above complaint number.

Based on interviews and record reviews, it was revealed that on 12-18-2024 at approximately 11:45pm, a staff member was doing rounds. When staff member entered room of R2, staff observed R1 running into the bathroom belonging to R2. Staff member then redirected R1 and informed R1 he was not to go into other bedrooms. Based on interview and record review, staff member questioned R2 as to the nature of R1’s presence at which time R2 revealed he was touched inappropriately by R1. A review of R1’s IPP dated 7/22/2024 revealed R1 is to be in “line of sight” supervision at all times due to a previous documented history of behaviors.

As a result, there is a preponderance of evidence to conclude staff did not provide line of sight supervision at all times as required and stated in R1's IPP. As a result of today’s case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.