Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent unannounced Case Management - Incident visit to continue the investigation of a self-reported incident that was initially conducted on 03/04/2025 between 09:15 a.m. and 11:00 a.m. Upon arrival, the LPA met with Program Director, Joseph Laporte and explained the reason for the visit. Entrance interview.

During today’s visit, the LPA conducted interviews with five (5) staff between 9:45 a.m. and 11:30 a.m.

On 02/21/2025, the Department received an incident report stating that on 02/20/2025 there was a staff shortage at the day program which left the participants to be left unattended for certain periods of time. Additionally, the staff shortage resulted in the staff to participant ratios to be off as there was not enough staff to follow the necessary staff to participant ratios.

Records reviewed and interviews conducted revealed that the program currently has three (3) participants who require 1:1 staffing, while all other participants are on a 3:1 ratio. Interviews further indicated that, although management occasionally assists by supervising some participants to maintain the required staff-to-participant ratios, this is not always possible. It was reported that, due to insufficient staffing, employees assigned to 1:1 participants have, at times, also been required to supervise an additional participant, thereby exceeding the intended staffing ratio.