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13 | Licensing Program Analyst (LPA)Tiffany Holmes contacted the facility to deliver findings for a complaint investigation via tele-virtual. LPA identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Alexis Garcia, Program Director.
Licensing Program Analyst (LPA) Domingo previously conducted a tour, made observations, and obtained and reviewed pertinent records on 10/01/2024. LPA Holmes was assigned this complaint on 02/24/2026 and conducted interviews with clients, staff, and outside sources. It was alleged that lack of supervision resulting in injury occurred. Interviews with outside sources revealed that the prior Program director at that time the complaint came in confirmed they did not see bruising on client's ears or wrists, but confirmed they did see one bruise on client's biceps and one on client's abdomen. Interviews revealed that while the client's adult diaper was being changed on Friday 09/20/2024, no bruising was observed on client before client left to go home. Interviews revealed that the day program was monitoring the bruising on client. Interviews with outside source revealed they are unsure where client is having the bruising inflicted at. Interviews revealed that the facility staff was monitoring the client, and documenting on a body image sheet showing marks on the diagram where the clients bruises were and the days the client had them. Interviews with staff revealed they denied the allegation of lack of supervision resulting in the client being injured. Interviews with another outside source revealed the client has behaviors and throws themselves down on the ground while having these behaviors and gets brusies by doing that frequently. Accroding to the clients Individual Service Plan (ISP) it is noted that the client is physically aggressive with peers & staff members, throws themself to the floor and refuses to get up.
LPA observations, and records review, it was determined that the complaint allegation is unsubstantiated. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.
An exit interview was conducted with Alexis Garcia, Program Director via face time and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided via email. An electronic email read receipt confirms the documents were received. |