Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20260320121114). The purpose of the visit is to issue citations for deficiencies observed during the complaint investigation unrelated to the complaint. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel. Upon arrival at approx. 10:15 a.m. LPA and QAS met with Administrator Ernest Federer and explained the reason for the visit.

On 03/20/2026, The Department received a complaint alleging that “Staff did not prevent client from pushing someone”, “Staff did not prevent a client from punching others”, “Client sustained injuries due to staff neglect”, “Staff did not ensure client had clothing items on” and “Staff yelled at client”. It was further stated that Administrator Ernest Federer was yelling at Client #1 (C1) in frustration, escalating the situation, therefore, was asked to leave by the Police at the scene. Per the Reporting Party (RP), Administrator acted unprofessional and did not utilize proper deescalation techniques.

On 03/24/2026, LPA along with the QAS conducted an initial 10-day complaint visit to investigate the above allegation. At approximately 09:30 a.m. LPA conducted a tour of the physical plant, interviewed staff, clients, and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 05/05/2026, LPA reviewed Police body cam footage of the 03/19/2026 incident between approximately 02:03:35 p.m. to 02:05:30 p.m.