Facility Evaluation Report

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent Case Management visit to issue final findings on an Incident that happened on or around 1/1/23. LPA conducted the investigation with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa and interviewed clients, and staff on 1/11/23, 2/17/23, 3/8/23, 3/13/23, 3/27/23, and 3/28/23. LPA and QAS met with Administrator and Director of Residential Services and explained the purpose of the visit.

CCL received an incident report on 1/04/23 stating that on 1/03/23 staff noticed Client 1 (C1) had bruising on left inner part of their eye and when asked what happened, C1 stated Staff 1 (S1) threw a water bottle at them on 1/1/23.

Interviews with Staff revealed C1 had a bruise most staff noticed on 1/3/23. One AM staff stated they noticed a small mark on C1’s eye on 1/2/23 and talked to the NOC shift about it, and NOC said they had already reported it to the Administrator. The staff later found out that was not true and realized they should have reported it sooner. When LPA interviewed the NOC staff, they stated they had informed the Administrator by phone and put the observation in the notes. LPA reviewed C1’s ID notes from 12/26/22 through 1/10/23, and observed there were no notes about a bruise under NOC shift for 1/1/23 through 1/3/23. On 1/3/23 during the 8am-4pm shift there is a note about staff observing a bruise and C1 stating it is from a staff throwing a water bottle and hitting C1.

All staff interviewed stated C1 makes up stories, but most staff stated those stories change often, but this story stayed consistent. When asked, most staff said they believed the story due to it staying the same every time repeated. When asked about S1, one staff stated they “had anger issues, you can see it in their eyes”, and a second staff stated they witnessed S1 “cuss and yell at clients”. Administrator stated after hearing about the incident they put S1 on administrative leave while they investigated. Administrator said due to C1’s history of making up stories and C1 repeatedly changing the date the incident happened and adding things to the story, they allowed S1 to come back to work but at different facility. Continued on 809-C (pg2)