Facility Evaluation Report

Licensing Program Analyst (LPA) Jenny Olson a conducted a Case Management - Deficiencies visit to the facility above. LPA met with Administrator, Chris Patton and explained the purpose of the visit. These deficiencies were observed by Department of Developmental Services and CCL during a semiannual visit conducted 1/17/2024, and by Tri-Counties Regional Center staff on visits on 1/7/2024, 1/9/2024, and 1/10/2024.

It was observed that the facility did not have adequate staffing and was not in ratio on multiple shifts. Based on a staffing review, multiple open shifts were observed 7/30/23-8/5/23, 8/13/23-8/19/23, 9/17/23-9/23/23, 10/1/23-10/7/23, 11/12/23-11/18/23. Additionally, the facility was out of ratio on 1/7/24, 1/9/24, and 1/10/24.

It was observed that Staff 1 (S1) did not have first aid training completed. It was also observed that 6 staff had less than the required 16 hours of emergency intervention training, and some of those staff had participated in restraints without proper training.

It was observed that multiple lead staff did not meet the requirements of lead staff per the program plan, which include obtaining a Registered Behavior Technician certification within 2 months of employment, or if they are a Licensed Psychiatric Technician or Qualified Behavior Modification Professional.

It was observed that two out of the three clients did not have an Individual Program Plan (IPP) on file as required per the program plan.

It was observed that although staff had completed DSP 1 and 2 training as required, they were completed outside of the required timeframe.