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32 | Regarding: Administrator is not present in the facility an adequate time to administer the program.
It is alleged that since 3/2026, the administrator is “in and out,” shows up occasionally and then leaves.
Interviews with (8) out of (8) staff indicated that the facility has an administrator who is always present at the facility and is present at the facility an adequate amount of time. Staff stated that S1, who is stationed to work at the facility full time, Monday - Friday, 7:30 a.m. – 4:40 p.m. conducts administrative duties, daily. Staff indicated that administrator #2 (S2), who is overseeing a sister facility, conducts visits to this facility (3) to (4) times per week for (1) to (2) hours per visit. Interview with S1and S3 indicated that when S2 is not at this facility, S2 is checking in daily with S1 and S3 via phone calls. S1 and S3 further indicated that when S2 visits the facility, they provide administrative support where needed. Interviews with (5) staff indicated that S1 is always at the facility providing administrative support and following through with duties. Five staff further indicated that if S1 has to step away for lunch or on scheduled breaks, S1 informs staff before stepping away. Review of S1’s timesheets indicated that S1 is at the facility Monday – Friday, 7:30 a.m. – 4:30 p.m. LPA conducted interview with C1 and C2 and they indicated that staff are nice and their needs are being met. LPA was unable to interview additional clients due to communication limitations. Interviews conducted and record reviews do not corroborate the allegation that the administrator is not present an adequate amount of time to administer the program.
Regarding: Licensee does not ensure staff provide adequate care and supervision to clients.
It is alleged that there is not adequate administration of the facility ensuring that staff are interacting with clients instead of just sitting around.
S1 – S3 deny the allegation. Interviews with S1- S3 indicated that the facility provides adequate supervision of staff to ensure that staff and clients are engaged during the day. S1 – S3 stated that since S1 was hired in March 2026, facility staff have received refresher training regarding staff and client engagement which was conducted on 5/20/2026. S1-S3 further indicated that staff interact with clients during the planned and open-ended activities that take place every day. Interviews with (4) out of (5) staff who work directly with the clients in care stated that they engage with clients during day program routines. Staff stated that they engage with clients by communicating with them and planning and preparing for activities using the facility’s “Choice Board.” Staff indicated that the “Choice Board” is updated weekly so that activities can be rotated to promote variety and interest. Staff further indicated that they encourage engagement by providing activities like exercise, art, games, and conversations.
***Continues on LIC 9099-C***
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