Facility Evaluation Report

Licensing Program Analyst (LPA) Nakagawa arrived unannounced to follow up on a self-reported incident involving a client C1. LPA was greeted by Care Team including Administrator Heidi Norietsa.

The facility self reported on 12/05/2024 that C1 was exhibiting behaviors, including possible self-harm. Administrator who is a nurse was able to assess C1 and found no evidence of self-harm, but rather attention-seeking. Administrator stated that C1's current Individual Behavior Support Plan (IBSP) was being met, however C1's care team meets weekly and will discuss the incident. C1 will continue with the IBSP which includes constant line of sight supervision, with additional supports given as needed.

LPA reviewed records and made observations.LPA toured portions of the facility and found the environment, including C1's room to be free from hazards. Sharps and electrical cords are locked and stored in staff office, along with cleaning supplies.

No deficiencies found at time of inspection.