Incident investigation·September 19, 2023

Licensing Program Analyst (LPA) Claudia Gutierrez conducted an unannounced case management visit for the purpose of following-up on an incident report submitted to the Department on 9/07/23. LPA was greeted and granted entry by Staff 1 (S1) Edy ”Janet" Santiago and explained the purpose of the visit. Assistant Administrator (AAD) Carmen Nunez was contacted by phone and arrived at 11:15 a.m. Incident report indicated that Staff 1 (S1) and Staff 2 (S2) had reported irregularities regarding Staff 3 (S3). An internal investigation was conducted, and no irregularities were found. The decision was made to relocated S3 to a sister facility and no further incidents have been reported. Upon follow-up, irregularities were found to pertain to residents’ personal rights. LPA interviewed S1 who corroborated incident was a personal rights matter. S2 and S3 were not present to be interviewed. LPA interviewed all six facility residents and two additional staff. LPA obtained copies of Personnel Report (LIC500), staff schedule, and staff contact information. LPA informed AAD that subsequent visits and document requests could be required regarding the incident and AAD stated they understood. No citation were noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.