Facility Evaluation Report

On 07/10/2026 at 11:00 AM, Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD) on 07/08/2026. LPAs met with Program Director, Shar Foox, and explained the purpose of the visit.

According to the Unusual Incident Report (UIR), on 07/07/2026, client (C1) made threatening statements toward staff, continued to antagonize staff members, and was escorted from the facility by local law enforcement.

LPAs interviewed staff regarding the incident. Staff member (S1) stated that C1 made threatening statements and gestures toward staff, causing S1 to fear for their safety. Staff member (S2) stated that during dinner, all clients were instructed to wash their hands in accordance with the facility's house rules. S2 reported that C1 initially refused, stating they had already washed their hands. C1 subsequently complied with the request but became increasingly agitated during dinner and began making aggressive statements toward staff. S2 stated that C1 continued to antagonize staff despite verbal redirection. S2 notified Staff member (S3), who contacted local law enforcement. Law enforcement responded to the facility and escorted C1 off the premises without further incident.

LPAs reviewed and obtained copies of C1's Admission Agreement, Physician's Report, and Appraisal.

No deficiencies cited. An exit interview was conducted, and a copy of this report was provided.