Facility Evaluation Report

At approximately 10:20 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator Jose Hernandez, who arrived at 11:15 AM. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report: CCL received an incident report on 10/11/2024. Report states that on 10/09/2024, Client 1 (C1) became agitated while Staff 1 (S1) was preparing him for bed. Staff 2 (S2) came in to assist. C1 swung at S2 and made contact. S2 did not use proper CPI techniques; reacting and making contact with C1's face. S1 was able to de-escalate situation. S2 was sent home per facility protocol. S2 was terminated that day as Licensee has a zero-tolerance for staff not following CPI training and protocols. Facility made all appropriate notifications per regulation.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.