Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management Deficiency visit in conjunction with complaint visit (CC #29-AS-20230130113402). LPA met with Administrator, Danshelle Day. The purpose of this visit is to issue citations for deficiencies observed during the complaint investigation which were not related to the complaint allegations.

The investigation revealed that staff member(s) “have known” of C1 and C2’s inappropriate and sexual behavior(s) “for a while” since October 2022. The staff observed some inappropriate interactions between C1 and C2 and elevated their observations to supervisors. Staff indicated that the sexual encounters appeared to have been consensual. Staff member(s) admitted to witnessing the inappropriate behavior(s) between C1 and C2 and had only been redirecting the behavior(s); but “never reported or documented any of the incidents” until January 2023.

In January 2023, there were two separate incidents that occurred on 01/11/2023 and 01/23/2023, of which staff member(s) witnessed C1 and C2 engage in sexual behaviors and tendencies. Staff #1 (S1) and Staff #2 (S2) reported these incidents to upper management, but never documented or reported (to CCL, APS, police, or C1’s resident representative) until 01/29/2023 in a Special Incident Report (SIR).

Citation issued, exit interview, appeal rights given.