Facility Evaluation Report

Licensing Program Analyst (LPA) Teresa Camara arrived at 9:56 a.m. for an unannounced Case Management visit to the facility to issue findings for an incident reported to the Department on 5/12/2021. The investigation was completed by LPA Ashley Smith, alongside Tri-Counties Regional Center Manager Freddie Garcia. The LPA met with administrator Ramon Junio and explained the reason for the visit.

The facility self-reported an incident on 5/12/2021, which described that on 5/11/2021, Client #1 (C1) had a behavioral episode, which led to staff allegedly performing a hold on C1 until the police arrived. During the initial visit on 7/13/2021, documents were reviewed, and the LPA interviewed staff at 1:10 p.m., 2:07 p.m., 2:36 p.m., and 3:20 p.m.; and, interviewed C1 at 2:49 p.m. Additional staff interviews took place on 8/20/2021 at 2:11 p.m., and on 9/28/2021 at 1:10 p.m. and 1:41 p.m. A police report pertaining to the case was subpoenaed and reviewed, and an interview with the responding officer took place on 8/5/2021 at 10:25 a.m. Body camera footage pertaining to the 5/11/2021 incident was also subpoenaed and obtained.

Interviews revealed that during the incident that took place on 5/11/2021, C1 became physically and verbally upset, began destroying property and threw a large rock at Staff #1 (S1). As a result of C1’s escalating behaviors, S1 used a single-person physical intervention to restrain C1. Interviews and reviewed footage noted that C1 was held in this position for approximately eight (8) minutes without additional staff assistance. The police arrived, and additional interviews confirmed that upon their arrival, the responding officer witnessed S1 on top of C1, holding C1 to the ground. S1 then released C1, who was then transferred to the hospital for a 5150 hold.