Facility Evaluation Report

Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit regarding an incident that occurred on 02/23/2024. LPA was greeted by staff and licensee joined about 20 minutes later LPA explained the reason for the visit.

The department investigated this incident and it was determined to be substantiated. The Department conducted interviews with three staff members and residents. Admin, S1, S2 and collaborating agency representatives(See confidential name list LIC-811 dated 5/03/2024) all provided statements to the department that confirm that R2 had a history of bringing potentially dangerous objects into the facility upon returning from community outings. Based on records reviewed the facility failed to create a plan to prevent R2 from bringing items into the facility that could be dangerous. R1 was stuck with a crowbar by R2. S1, S2, R1, R2 and the Administrator confirm that the incident occurred.

During the investigation, it was found that there were other incidents were R2 had brought items into the facility and staff would not check R2'S room and bags to see if there were any items that could cause harm even though a plane was to have been put in place for this, also the facility failed to report incidents with R2.

Deficiencies are being cited from the California Code of Regulations (CCR) Title 22, Division 6. A civil Failure to correct the deficiencies may also result in civil penalties.

Exit interview and copy of report and appeal rights given.