Based on interviews and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Citations issued, please refer to LIC 9099-D.

A civil penalty for $100 per day for a maximum of 5 days in the amount of $500 for criminal record clearance violation is being assessed on the attached LIC 421BG.

The Administrator was informed that additional citations may be issued at a later date.

No other immediate health and safety issues observed during the day of the visit. Exit interview was conducted, appeal rights given and a copy of this report was provided to the Administrator.

Regarding the allegation: Staff works in the facility has no criminal record clearance. It was alleged that S2, S3 and S4 are working at the facility without approved criminal background clearance. To investigate the allegation, LPA interviewed one (1) staff member. Upon arrival, LPA observed there to be eight (8) staff members. LPA requested all staff to provide their names in writing. LPA’s record review of both the Department of Social Services: Guardian Background Check System and Licensing Information System (LIS) databases, confirmed all three (3) staff members (who no longer work at the facility) were shown to have approved background clearance for the facility. However, LPA observed one (1) staff member (S10) of the eight (8) present staff members to have a “pending” criminal background clearance. LPA’s interview with S1 revealed they believed S10 had been cleared.

Based on interviews, observations, and record review, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Regarding the allegation: Staff providing medication assistance has no medication training. It was alleged S4 did not have proper training regarding medication assistance including other staff. To investigate the allegation, LPA conducted interviews with one (1) staff member. LPA’s interview with S1 revealed staff needed to be trained and complete their Direct Support Staff (DSP) training prior to assisting with medication. When questioned if S4 had DSP certification, S1 stated, “No”. During LPA’s record review of the clients’ Medication Administration Records (MARs), LPA observed S4 to have dispensed medications in the months of May 2026 and June 2026.

LPA’s record review of the facility’s Plan of Operation revealed, “All staff are trained by the administrator using the Technical Support Program” guidelines from Community Care Licensing” (page 29). LPA’s record review revealed S4’s 40-Hour Orientation dated 2/10/2026 showcased S4 to have received Medication Procedures training on 2/5/2026.

(continue to LIC 9099-C)

LPA’s supplementary record review of video footages provided to Community Care Licensing Division (CCLD) revealed the following:

In video #one (1), S2 can be observed restraining C1 by both of their wrists while C1 is sitting on the floor maneuvering in a back-and-forth motion. S2 can be heard stating to C1, “You understand. You do not do that to me, okay…” which then S2 can be observed striking C1 with an open hand across their cheek four (4) times. C1 can be observed to attempt to curl their body inward and shield themselves from S2 by maintaining their head down. C1 can be observed to produce sounds of physical distress. Additionally, S2 can be heard calling C1, “Stupid”.

In video #two (2), S3 and S4 can be observed restraining C1 by each of their wrists while positioning them to sit on the couch. S4 can be observed twisting C1’s right arm inward towards the bottom of their chin. S3 can be observed telling C1, “What is wrong with you?” approximately six (6) times while S4 maintains the restraint position of C1. C1 can be observed to produce sounds of physical distress.

In video #three (3), S4 can be observed standing above C2 while they are sitting on a couch. S4 can be observed to attempt to restrain C2’s arm where C2 proceeds to state, “No No” while attempting to use their right arm to push against S4’s attempt of restraining their arm. S2 can be observed to approach C2 and state, “Sing and shut up, sing”. S2 can be observed to kick C2 on their left leg.

In video #four (4) and #five (5) S4 can be observed standing over C2 while C2 is sitting on a couch.

Additional record review of the facility’s Plan of Operations revealed the facility did not have an Emergency Intervention Plan within their program design nor was an Emergency Intervention Plan approved by CCLD, “Prone containment or any other physical form of restraint is not to be used at any time” (page 39).

On 7/10/2026 LPA received a telephone call from S3 where they confirmed they restrained C1 by their wrist along with S4 due to a behavioral episode. (continue to LIC 9099-C)