Facility Evaluation Report

At 1:00pm on 06/06/2022 An announced virtual Office Meeting was conducted to discuss concerns regarding recent complaints and citations at this facility, and concerns called in to Community Care Licensing (CCL) from members of the community.

Present at today’s meeting were: Licensing Program Analyst (LPA) Mark Jeffries, Licensing Program Manager (LPM) Kelly Burley, Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Vincent Figueroa , TCRC Quality Assurance Manager Freddie Garcia, and Licensee Representatives Abe Avila, Richard Rubio, Christopher Trevilla, Joanna Iniguez, Maria Drummond, Michelle Mainez.

· LPM discussed an incident where a lack of staff supervision led to a client leaving the facility without staff’s awareness. The client walked into a neighbor’s home at night, and the neighbor alerted the facility about the client’s whereabouts.

o Licensee Representatives stated they were retraining all staff on various topics including AWOL/elopement procedures and preventing and managing elopements, personal rights, line of sight, and missing person protocols for each client.

o LPM also suggested to check that door alarms placed on egress doors are functional. TCRC QAS recommended checking fence alarms as well.

· LPM discussed a recent incident where a staff improperly restrained a client, and the restraint was not reported to CCL. Additionally, when interviewed, the staff denied having CPI training even though a training certificate indicates the staff had the training about two months prior to the incident.