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25 | Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management - Incident visit regarding 2 Serious Incident Reports (SIR) from the facility received on 07/25/2023. Today’s visit was conducted on-site in collaboration with a Tri-Counties Regional Center representative. On 07/25/2023, the facility submitted 2 SIRs and 2 Reports of Suspected Dependent Adult/Elder Abuse (SOC 341). The 1st SIR documented that on 7/21/2023, Staff member #1 (S1) stated that Client #1 (C1) had been left in a facility van unsupervised by Staff member #2 (S2) for a period no less than 3 hours in length with no food or water. The back window of the van was rolled down after C1 had been in the van alone and unsupervised for at least 1 hour. This occurred away from the facility at//near the personal residence of S2 with relatives of S2 periodically walking to the van to verbally abuse C1. The 2nd SIR documented that on 7/24/2023, Staff member #3 (S3) had witnessed Staff member #4 (S4) using improper restraints on C1, tying C1 to a chair. The accusation stated that S4 did this multiple times on an ongoing basis. The LPA received a cross report from Adult Protective Services (APS) on 07/28/2023 as well as photographic and video evidence of the incidents from the facility on 07/31/2023 via Tri-Counties Regional Center. During today's visit, the LPA interviewed facility clients, Staff member, the Administrator, and requested documents pertinent to the investigation. During the course of the Case Management visit today the LPA and Tri-Counties Regional Center Representative received information and investigated 2 additional SIRs regarding improper restraint used on Client #2 (C2) on 6/20/2023 and 7/28/2023. On 6/20/2023, C2 stated they were held down in a prone position for no more than 10 minutes by S3. On 7/28/2023, LPA received an SIR that stated S3 had been verbally abusive to clients in the facility. During today's visit, the LPA contacted the Human Resources (HR) of the facility. HR stated they had re-submitted the 6/20/2023 SIR with additional information and that they would email the LPA further information about the SIR. Further investigation is required before final findings are delivered. During today's Case Management Visit, administrator had an appointment for a client and was forced to leave prior to the LPA obtaining a signature on the Case Management Report.
No health and safety hazards noted at this time, and no citations were issued. Exit interview conducted. Copy of the Report issued to the facility. Administrator signature on file
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