Facility Evaluation Report

On 8-9-23 at 2:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding resident to resident altercations and a previous incident regarding client possession of cannabis edibles. LPAs met with Program Director (PD) Michael Carroll and explained the purpose of the visit. During today's case management, LPAs reviewed incident reports dated 7-14-23 an 7-27-23 and interviewed PD.

Based on incident report dated 7-14-23, resident1 (R1) was witnessed by day program staff to be licking a container which was in R1's possession. Staff1 (S1) inquired what R1 had in possession and R1 stated: "just my cannabis." Day program staff witnessed a container marked "cannabis" Based on interview, it was determined that the items in the container was candy placed by R1's family member who marked the container "cannabis" as R1 has a history of desiring various drugs, and R1's family member used the marked container as an attempt to redirect R1 from desiring and potentially seeking drugs. Incident was reported to Department and other entities per regulatory requirements.

Based on incident reports dated 7-27-23, R2 and R3 engaged in a resident to resident altercation. Incident reports state R2 charged towards R3 and slapped R3 in the face causing redness. Day program staff provided general first aid including ice pack. Incident was reported to Licensing department, ombudsman, police department and other entities per regulatory requirements. It was revealed through interview, that R1 has engaged in multiple resident to resident altercations which have been reported accordingly. Interview also revealed additional resident to resident altercations within the last 30 days.

LPAs discussed with program director possible solutions to help mitigate resident to resident altercations. At this time program director as agreed to the following: (1)Licensee or designee will ensure continued additional staff training on various mental health topics including but not limited to: De-escalation of behaviors and peer conflicts, identifying triggers for various behaviors, safe intervention techniques regarding aggression and anger. {Cont. on 809C}.