Facility Evaluation Report

On 7/31/2025 at 10:40am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident. LPA met with Mary Ann Leyba, Administrator, and explained the purpose of the visit.

The incident occurred on July 28, 2024, involving S2, C1, and W2.

On July 28, 2024, an incident occurred where W2 was injured during a physical altercation with C1. C1 is a resident of Concord House and W2 was visiting from her Independent Living Skills (ILS) home. During the incident, C1 was escalated and attempted to retrieve the facility keys from Concord House staff S2. S2 handed W2 the keys in an effort to redirect C1’s escalating aggression away from staff instead of de-escalating the situation. C1 forcibly grabbed W1’s hand and bent W1’s fingers back, which resulted in a fracture. Following the event, W2 was instructed to ice her hand and returned to her residence. Concord House staff did not seek medical treatment for W2 at the time of the incident, nor did they notify her conservators.

On July 29, 2024, W2 returned to Concord House with a visibly swollen and bruised hand. Staff acknowledged the injury, advised W2 to continue to apply ice, and sent her to her day program. Upon arrival, day program staff