Facility Evaluation Report

On 10-23-23 at 1:04pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding an incident which occurred on 9-7-23. LPA met with Program Director Michael Carroll and explained the purpose of the visit. LPA reviewed incident report dated 9-8-23 and briefly interviewed Administrator. LPA also reviewed facility file documentation including debriefing and staff training certifications. Based on interview and records reviews, on 9-7-23, resident1 (R1) engaged in aggressive and assaultive behavior towards staff including kicking the exterior door of facility. At approximately 11:35am, R1 ran into building and began threatening staff on duty with physical harm. R1 then ran outside of facility and staff cleared other participants from the area for safety. R1 then began to charge staff with swinging fists. Staff then used non-evasive crisis intervention (NCI) techniques to evade and de-escalate situation. Staff then notified R1's responsible person who arrived at facility and was also threatened by R1. Based on incident report and interview, it was revealed during responsible party's visit that R1 had various missed dosages of medication while living at home. It was further revealed that R1 began to physically assault staff which prompted staff to place R1 in a medium risk level standing hold. Additional multiple hold were placed on R1 due to repeated attempted to assault staff. An additional behavior of R1 disrobing self also occurred. Facility staff called 911 and police arrived to transport R1 to county mental health.

Incident was reported to licensing department and ombudsman within regulatory time frames. A debriefing dated 9-8-23 was completed and addressed necessary interventions used and signed by four staff members including program director. A Notice of discharge was given to R1 and responsible party on 9-11-23 due to above incident. A copy of this notice was provided to licensing within regulatory time frames. A meeting between facility, regional center, R1, and responsible person for R1 was conducted to discuss additional resources for R1. Review of staff files revealed that all staff involved incident were appropriately certified and trained.

As a result of today's case management, no citations were issued. An exit interview was conducted with Program Director Michael Carroll and a copy of this report was provided to Michael.