Facility Evaluation Report

Licensing Program Analyst (LPA) Olson conducted a Case Management visit to address the deficiencies noted during complaint control # 29-AS-20230124162800 investigation. LPA met with Estella Usher, Administrator and explained the purpose of the visit.

Based on the investigation conducted, after C1 had already eloped the morning of 1/20/2023, Staff 1 admitted to observing C1 in the kitchen with their hand on their teeth and then a can on their teeth. Interviews revealed S1 said they thought C1 was picking food out of their teeth, even though they were holding a can to their teeth. S1 did not provide any interventions or redirection of C1, and walked back to assist C2, leaving C1 unsupervised. S1 stated they came back to kitchen and C1 was hitting their tooth with the can. S1 asked what they are doing? What’s wrong with your teeth? Does it hurt? C1 replies, “you don’t think I can do it? I can pull out my teeth, I can pull out my teeth. Nothing is wrong, I’m going to pull it out.” S1 stated they think their questions were taken as a challenge. S1 stated they told C1 to go to their room and listen to music, again not providing C1 with adequate supervision after S1 observed C1 hitting their teeth with a can. The investigation revealed this incident happened in about 15 minutes. C1 had pulled out their tooth before moving into the home, and the Administrator was aware of that but it was not in C1’s Individual Service Plan. Although C1 did not require one on one supervision and does not need assistance with ADLs, adequate supervision was not provided after S1 witnessed C1 in the kitchen touching and hitting their teeth with a can, and redirected C1 to their room, where there was no supervision. Additionally, Technical Assistance is issued to ensure staff have adequate training to handle client behaviors and appropriately address them.

At 10:35 AM LPA Olson observed one staff and one consultant in the facility near clients not wearing a mask.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit Interview completed, copy of the report and appeal rights were emailed and printed.