Facility Evaluation Report

On 04/24/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial investigation for a Case Management - Incident visit on-site in collaboration with a Tri-Counties Regional Center representative. LPA met with Administrator Rea Hallmon and explained the purpose of the visit.

This Case Management - Incident visit is regarding an Incident Report (SIR) from the facility received on 04/09/2024. According to the SIR, on 04/06/2024, Staff member of the facility (S2) telephoned the facility house manager (S3) to inform them of an alleged incident that occurred 04/01/2024. According to S2 a client in care at the facility (C1) stated that a Staff member (S4) had dragged the client by their feet off their bed as they were laying down and dropped the client to the ground, which led to the client sustaining back injuries. The SIR included an attached Report of Suspected Dependent Adult/Elder Abuse (SOC 341). According to the Licensee, the facility placed S4 on leave as of 04/08/2024. According to the SIR and through interview of the facility administrator (S1) during the Case Management visit, a wellness check/body check was performed on C1 immediately after the incident occurred by C1's Licensed Marriage and Family Therapist (LMFT), Witness #1 (W1). The facility stated a plan to prevent further occurrences was to implement Staff retraining on Zero Tolerance Policy, mandated reporting, and Client Personal Rights. The Licensee stated that the facility will cooperate with any organization/regulatory agency for any required investigation and/or review. The LPA received a cross report from Adult Protective Services (APS) on 04/10/2024 that indicated an Administrator from a separate facility under the LIcensee, Staff #5 (S5), contacted APS and was planning to contact Law Enforcement. S1 stated to LPA and TCRC during this Case Management visit that Law Enforcement Officers came to the facility on 04/10/2024 to speak with C1. A copy of the report will be given to LPA and TCRC. S1 also stated an internal investigation is ongoing at this time while S4 is on leave.

During today's visit, the LPA interviewed facility client(s), Staff members, the facility Administrator, and requested/received documentation pertinent to the investigation. Continued on 809-C