Facility Evaluation Report

On 8-25-23 at 10:02am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a resident to resident altercation reported on 8-1-23. LPAs met with Program Director Sherry Welker-Loza and explained the purpose of the visit. LPAs reviewed incident report dated 8-1-23 with program director. Based on record review, it was determined that on 8-1-23 at approximately 12:05pm, resident1 (R1) experienced a behavioral episode in which R1 struck R2 on the left side of R2s forehead with a closed fist and bit R2 as well. Basic first aid was applied by facility staff as appropriate due to a minor scratch. Behavior intervention was applied and both residents were separated. Incident was reported to licensing department, ombudsman, and local law enforcement as required.

During today's case management, LPAs discussed with program director additional interventions and resources due to previous resident to resident altercations and behavior episodes reported to the department. LPAs also reviewed current staff training documents. Program Director confirmed day program is currently implementing and has agreed to continue the following: (1) Staff training on trigger behaviors, (2) Crisis intervention training, (3) Updating plans of care for consumers who exhibit new or worsening behavior episodes, (4) On-going behavior charting, and (5) Continued 1:3 staffing ratio for increased supervision. Program director is made aware of that LPA may continue additional visits to monitor behavior charting and other staff training documentation.

As a result of today's case management, no citations are issued today. An exit interview was conducted with Sherry Welker-Loza and a copy of this report was provided to Sherry.