Facility Evaluation Report

On 2-7-23 at 1:12pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding a reported incident from 1-31-23. LPA met with Assistant Administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit and purpose. LPA reviewed incident report with Assistant Administrator and conducted interview with Assistant Administrator. Based on record review and interviews conducted, it was determined that on 1-31-23 at approximately 7:30am, resident1 (R1) came downstairs and was noted by facility staff on duty to have a left black eye. Facility staff asked R1 how R1 obtained black eye. According to incident report, R1 stated the black eye was caused by falling out of bed. On the same date according to incident report, after R1 arrived at day program, Administrator spoke with R1 via telephone at which time R1 disclosed the black eye was caused by R1 being hit by another resident (R2) at facility on the morning of 1-31-23 prior to breakfast. At this time, R1 is not at facility and residing at a respite facility arranged by regional center. It is undetermined at this time if R1 will be returning to facility.

An incident report was received by licensing department on 2-1-23. Based on record review, facility has updated R1's file to reflect event described above and R1's on-going behaviors. Based on interview, it was determined that report was not sent to ombudsman and local law enforcement from facility per regulatory requirements.

As a result of today's case management visit. Citation are issued under Title 22, Division 6. A civil penalty in the amount of $250 is issued as a result of a repeat violation within a 12-month period. An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal rights provided.