Facility Evaluation Report

Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent case management visit to deliver findings for a case management investigation related to an incident report received on 12/28/2022. LPA initially met with facility staff. Administrator arrived at 10:25AM and LPA explained the reason for the visit.

On 12/28/2022, the Community Care Licensing Division (CCLD) received a self-reported unusual incident report (LIC 624) and Report of Suspected Abuse (SOC341) pertaining to Client #1 (C1). C1 reported that their personal rights were violated while at the facility. C1 alleged that they were inappropriately touched by Client #2 (C2) at the facility. On 12/29/2022, the case was referred to the Community Care Licensing Investigations Branch (IB) and assigned to Investigator Christine Ferris.

On 01/03/2023, from 11:41am to 12:45pm, Licensing Program Analyst (LPA) Kelly Dulek initiated an unannounced Case Management – Incident visit for an Incident Report received at the Regional Office on 12/28/2022. LPA Dulek arrived at the facility at 11:41am and met with Administrator Tanya Kramer. The incident report indicated that Client #1 (C1) informed their family member that Client #2 (C2) had made unwanted contact with C1 on an unknown date about two weeks prior. C1 indicated they had not told staff at the time of the alleged incident. Facility staff were informed of the alleged incident by C1's family member. During the visit, LPA Dulek along with the Administrator toured the facility at 11:45am. No health and safety concerns were identified during the visit. The LPA also interviewed the Administrator throughout the visit and obtained copies of pertinent documents. The Administrator was informed that the Community Care Licensing Investigations Branch (IB) Investigator Christine Ferris would follow up regarding the incident.

Investigator Ferris conducted interviews on 01/12/2023 with C1; and on 01/17/2023, with Tri-Counties Regional Center (TCRC). In addition, the investigator reviewed facility file documents, including C1 and C2’s Person Centered Individual Program Plan (IPP), and C1’s 90-day Behavior Assessment and Support Plan.