Facility Evaluation Report

On 12/12/2025 at 9:15AM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conduct a Case Management visit regarding an Unusual Incident Report (LIC624) received on 11/18/2025. Incident involved a resident (R1) forcefully closing the pantry door causing the door to hit a staff member. LPAs met with house manager Dennis Valencia and explained the purpose of the visit. Facility is currently at capacity of six (6) residents.

LPAs collected the following documents during the visit: R1's ID sheet, R1's LIC602, R1's Appraisal Needs and Services Plan, R1's Individual Service Plan, R1's Behavior Intervention Plan (BIP), and R1's medication list.

LPAs spoke with the house manager regarding why the incident occurred, what steps have been taken to ensure similar incidents do not happen again, and to ensure resident compatibility. House Manager explained that R1 normally has a 1:1 staff to help with care. However, staff stepped away and the incident occurred right afterwards. A staff member was opening a pantry and R1 ran to the kitchen and shut the pantry on the staff, hitting them on their right shoulder blade. The incident was reported to R1's behaviorist (via email) and psychiatrists (via phone) afterwards, and the facility has a BIP to alleviate future incidents.

One Technical Violation was issued regarding staffing for residents requiring 1:1 supervision. No deficiencies cited during visit. Exit interview conducted and a copy of this report was made available to the House Manager.