Facility Evaluation Report

LPA Arrived unannounced for the purpose of conducting a case management following up on a self-reported incident involving a physical altercation between a staff (S1) and client (C1) on 9/28/2023. LPA interviewed Administrator and gathered staff (S1) files for department to review. S1 was placed on administrative leave and an internal investigation is currently being conducted for determination of corrective action for S1. Administrator will be providing LPA with documentation once determination is confirmed.

Client C1 was on an outing with staff during the visit but LPA was informed that C1 has not had any significant changes in behavior other than speaking less with staff and clients. C1 had expressed emotional distress to lead staff closer to the date of the incident. Facility is providing additional day outings for C1 to assist with de-escalation and ensuring C1 is able to re-integrate into a comfortable relationship with current staff. The facility failed to ensure the protection of personal right’s for client in care (C1). Deficiency was determined and citation issued under violation of personal rights and Title 22 Regulation. The facility will be implementing an in-person training on client personal rights, de-escalation and managing behaviors and is scheduled on 10/11/2023. Facility Administrator has properly followed up on the incident and ensuring further compliance and safety of clients moving forward.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.