37. Unannounced Visit: Sleeping Staff

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Facility Type: 730/733 (Group Home)

Investigation Findings
Licensing Program Analysts (LPAs) made an unannounced case management inspection at the facility and met with staff who assisted with the inspection.

Upon LPAs’ arrival, both staff were asleep on the couch. LPA knocked a few times before staff heard LPA at the door. Staff got up, put his shoes on, and opened the door.

LPAs conducted a walk-through of the facility. LPAs could not review client files as Unity Care #2’s Clinician has all client binders, and is auditing them. LPAs interviewed staff present about their individual needs and program goals. Water temperature measured at 109.4 degrees Fahrenheit, which is within the required temperature range.

LPAs reviewed facility menu and food on hand. The food present corresponded to the menu. Staff stated that for the Shepherd’s Pie scheduled for tonight, they would not know how to make that, so they will substitute that meal for something comparable.

LPA requested Staff then print out all clients’ Needs and Services Plans/Case Plans to review. Staff printed these out.

Deficiencies cited – See D-Page. An exit interview conducted with administrator, who created each POC. A copy of this report was left with the facility, as well as appeal rights.

Deficiency Type /
Section Number
Type A
Section Cited
Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.
Both staff present at facility when LPAs arrived were asleep, failing to provide care and supervision. Immediate risk.
Administrator stated both staff will be given a corrective action. Facility will submit the corrective action plans as discussed with these two staff to CCL by POC due date of 8/13/2018.
Type B
Section Cited
Furniture, Fixtures, and Supplies. The licensee shall provide to clients items used to maintain basic personal hygiene practices.
There were no hand towels in the client bathroom. Potential risk.
Repeat Civil Penalty Assessed. Staff were sent out to get paper towels. Facility will submit a picture of paper towels to CCL by POC due date of 8/12/2018.


Facility Report


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