Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Assistant Administrator Dvawntre Lattimore.

The purpose of the visit was to follow up with LIC624 Unusual Injury/Incident Reports (IRs) self-reported by the facility and submitted to the Department. On 08/11/2024, the facility submitted two IRs related to the same incident that occurred on 08/11/2024 at approximately 8:00 AM. The incident involved staff S1 and S2 and resident R1. S1 was assigned to provide one-on-one supervision of R1 while R1 was in the living room area of the facility. S2 was nearby in the facility kitchen area. S1 left R1 to go to the bathroom without notifying S2 that S1 would be leaving R1. S2 then left the kitchen area to go into the facility office that is located inside the facility garage. During visit, LPA observed a hallway between the kitchen area and the garage area that has been converted to an office. The office door has a keypad lock and the door automatically closes. S2 returned to the living area and observed that S1 was not providing one-to-one supervision of R1. When S1 returned, S2 told S1 that S1 did not provide one-on-one supervision of R1 and S1 made verbally aggressive statements to S2 in the presence of R1.

During visit, LPA Marrufo reviewed R1's Individualized Behavioral Support Plan that was dated 07/09/2024. Page 73 of R1's Individualized Behavioral Support Plan states that from 6:30 AM to 10:00 PM, R1 requires a 1:1 staff member within 0-10 feet and an Emergency Intervention Professional (EIP) at a distance to hear and support during behaviors of concern. During interview on 08/22/2024, Assistant Administrator Dvawntre Lattimore stated staff S1 was assigned as R1's 1:1 staff and S2 was assigned as R2's EIP staff.

See LIC809-C for more information. Page 1 of 2.