Facility Evaluation Report

Licensing Program Analyst (LPA) Alvisoi conducted an unannounced case management inspection, at approximately 9:45am on 12/5/23, and met with Melissa Cardenas- Program's Area Director. Day Services Manager, Shannon Davis, who is covering the Administrator position, was not available on site during the LPA's Inspection.

LPA conducted the case management to obtain more information on client incident reports of 11/20 incident. LPA reviewed client files, which included care plan, and crisis intervention plan; The Mandt technique is part of client's crisis intervention plan. LPA reviewed photos obtained regarding client injury/bruising to hands and wrists.

LPA reviewed staff files, including staff training., S3 is trained in this Mandt technique. LPA conducted interviews, including interviews with day program staff, S1 & S3, regarding the client incident. The staff grabbing/taking both C1's hands and holding them for no more than 10 minutes and letting go, was repeatedly used on 11/20/23 with C1. Per interviews, no calls were made to C1's responsible parties regarding clients behaviors having been escalated from 8am throughout the day at Program.

Per staff interviews, review of incident reports, and information obtained, client was at day program from approximately 8am to 3pm. The client had continued behaviors from the time of arrival to program, which resulted in staff using the Mandt techniques off and on continuously on the client from 8am to at least 2:15pm, when S3 left for the day.

The incident of C1 having behaviors all day at day program, and the continued use of the Mandt techniques by staff, resulted in several bruises to both hands and wrists of the client. Any form of manual restraint should not cause injury to the client. Staff need to be aware of length of time and/or time of continued use of restraint on a client.