Facility Evaluation Report

At 10:00am on 03/24/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct a case management visit. LPA accompanied Tri Counties Regional Center (TCRC), Quality Assurance Representative, Stephanie Cole (QA). QA and LPA met with facility Administrator Cindy Baker announced who they are and the reason for the visit. Case Management visit was made due to Serious Incident Report (SIR) submitted on 03/14/2025 for an incident that took place on 02/22/2025.

QA and LPA conducted staff interviews, conducted facility tour, make observations of all clients in care. LPA noted extensive administrative action, including but not limited to staff training, Register Nurse observations of Clients in care, Staff scheduling adjustments and staff care. LPA requested training documentation for Staff 1 and Staff 2 (S1 and S2). LPA will review documentation and follow up with Licensing Program Manager on status and updates on SIR submitted and facility actions pertaining to SIR in question.

Exit interview, report read, and report provided.