Facility Evaluation Report

On 08/15/2023, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct further investigation and to issue final findings for a Case Management - Incident visit. LPA met with Administrator Rea Hallmon and explained the purpose of the visit.

LPA conducted a previous Case Management - Incident visit on 07/31/2023 in collaboration with Tri-Counties Regional Center in which further investigation was required. LPA and Tri-Counties Regional Center Representative received information/documentation including Incident Reports (SIR) from the facility on 6/20/2023 & 7/28/2023 stating that one staff member had conducted an improper support hold on a resident in care on 6/20/2023. The facility alleged per the SIR that the resident was held face down on the floor in a prone position, with the staff member placing pressure on the resident’s back with their knee and/or placing their body weight against the resident’s torso and back for between 5 to 10 minutes. On 07/31/2023, the Resident stated to the LPA & Tri-Counties Regional Representative that they were held down in a prone position on their stomach by a Staff member for no more than 10 minutes which caused great discomfort and pain. On 08/14/2023, LPA received an email from the facility District Manager. The email indicated the Human Resources (HR) Department of the facility stated the Staff member acknowledged using the improper Crisis Prevention Institute (CPI) hold on the Resident on 06/20/2023. Facility HR stated the Staff member was candid with the internal fact-finding discussion by the facility as to the incident, and promptly acknowledged how the incident happened and evolved into an improper support hold. Additionally, HR stated the Staff member has completed 16 hours of CPI training and has been assessed for physical skills and de-escalation techniques.

At this case management visit the facility will be cited with a Type A deficiency for Emergency Intervention Prohibitions, Title 22 (22 CCR) Division 6, Chapter 6 Section 85102(a)(8).

Exit interview conducted, citation issued, appeal rights and copy of the report provided to the facility Administrator.