Facility Evaluation Report

On 3-18-25 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding incident report submitted by facility. LPA met with program director (PD) Candice Pelletier and explained the purpose of the visit. LPA conducted brief interviews with PD and resident1 (R1). Additionally, LPA reviewed incident report dated 1-15-2025 and requested individual program plans for R1 and R2.

On 1-15-2025, facility submitted an incident report stating that on 1-14-2025, R1 reported that another client (R2) touched her in an inappropriate manner. Interview conducted and incident report reviewed revealed that incident was not observed by staff. Additionally, it was revealed that staff reported incident as told by R1 to facility management and followed regulatory reporting requirement protocol including submitted reports to licensing department, ombudsman, and local law enforcement within 24 hours. Interviews further revealed that clients were separated after the reported incident as a precaution and per facility protocol for safety. Record reviews revealed behavioral interventions remain in place for R1 including various coping skills. Additionally, behavior interventions remain in place for R2.

As a result of today's case management, no deficiencies were observed. An exit interview was conducted with program director and a copy of this report was provided.