Facility Evaluation Report

Licensing Program Analyst (LPA) Erika Miller and Licensing Program Manager (LPM) Kelly Burley conducted a Case Management - Incident visit to the facility above. LPA met with Administrator, Chris Patton and explained the purpose of the visit. LPA was also accompanied by Quality Assurance Specialists (QAS) Vincent Figueroa and Stephanie Cole from Tri-Counties Regional Center (TCRC).

LPA reviewed the Debrief the facility submitted following an incident that occurred on 2/14/2024 to 2/15/2024. The Debrief was also reviewed in consultation with Department of Developmental Services and TCRC. The Debrief indicates multiple unapproved restraints performed by staff on Client 3 (C3), and staff restricted C3’s movement around the facility, including blocking C3 from exiting.

Staff 1 used an unauthorized restraint, placing their arms under C3’s armpits which limited C3’s mobility. Staff 2 placed their foot in front of the front door to prevent C3 opening the door and exiting the facility. C3 pushed through staff and entered Client 2’s room. Client 2 woke up and screamed “no” while crying. Staff attempted to redirect C3 out of the room but were unsuccessful. Staff then carried C3 out of the other client’s bedroom, which was an unapproved restraint. C3 attempted to go into the sensory room, which is used to help clients deescalate and calm down, but staff prevented C3 from going in the room, as they were concerned C3 may leave out the back door in the room. C3 went into the bathroom, stood on the toilet, and tried to crawl out the window. Multiple staff grabbed C3’s legs and pulled C3 out of the window and onto the floor.

LPA reviewed a staff schedule against the incident report and debrief. LPA observed that during the incident, the facility was out of staff to client ratio. The facility should have had 5 staff working for the 3 clients when the incident occurred, but only had 4.