Facility Evaluation Report

On 03/25/2026, at 9:15 am, Licensing Program Analysts (LPAs) K. Nguyen and L. Alexander arrived unannounced to conduct a Case Management visit regarding an incident that was reported to the Community Care Licensing Division (CCLD) on 03/23/2026. LPAs met with Campus Administrator, Michele Sheldon, and explained the reason for the visit.

The incident reported that Client 1 (C1) told a staff that an incident that was caused by Client 2 (C2) around 4am. Reported indicated that C1 was in the room sleeping and that C2 went inside C1's room and pissed on C1 while C1 was sleeping.

LPAs conduct file reviews and interviews with Client and Staff. When asked about the incident that happened on 3/23/26, C1 stated that C1 was sleeping and did not want to talk about it. Later, C1 stated that C1 was sleeping, and she knew that C2 had gone inside C1's room. When asked, C1 stated that “I was sleeping, but I know it was C2. I didn’t see C2's face, but I know it was C2.” When asked for more detail, C1 stated: “I don’t want to talk about it anymore”.

LPAs reviewed documents, including but not limited to staff rooster, client rooster, C1, admission agreement, physician report, need and service plan, and wellness check record every Quarter (Q) Q15min, and Q30min from March to present, show that C1 and C2 were observed to be in bed by NOC staff. S1 stated that “this is the first time I’ve heard something like this happened to C1”. S2 stated that S2 talked to C1 regarding the incidents. C1 replied, “I don’t want to say anything because I think people would not do anything”. S2 would reassure and encourage C1 to report if anything happened to C1.

No deficiencies were issued during the visit.

An exit interview was conducted, and a copy of this report was provided.