Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced case management visit in response to a Serious Incident Report (SIR) dated 2/21/2025. LPA met with Soriya Wilkins, program coordinator, and explained the purpose of the visit. LPA met with Angelica Real, Program Director, shortly thereafter.

During the visit, LPA interviewed Staff #1 - 3 (S1 - S3) and obtained the Intake Assessment, Facesheet, Individual Program Plan (IPP), Physician's Report, and Individual Service Plan (ISP) for Clients #1 - 2 (C1 - C2). LPA also toured the area in which the incident took place.

Based on the SIR dated 2/21/2025, an incident occurred involving C1 and C2 in which C2 rushed towards C1 and shoved them against the wall of the computer room. Staff intervened and separated the clients after the incident, and also notified the responsible parties of the two (2) clients, along with law enforcement and Adult Protective Services (APS). According to interviews with staff this is not the first time this has occurred, as two (2) separate incidents occurred on 9/11/2024 and 11/14/2024, in which C2 assaulted C1 once again by hitting them on the side of the head. Staff interviewed stated that they utilized a behavioralist to assess C2 before they were allowed back into the program on 2/24/2025. Staff stated that it appears that C2 had not displayed signs of aggression towards any other staff or clients, and therefore it appears that they had been targeting C1 exclusively. Based on these factors they determined that C2 will be removed from the program to prevent the risk of C1 being assaulted once again. Angelica Real explained that she will be emailing the police report number to the LPA either by the end of the day or by tomorrow.

Following today's visit, no deficiencies will be issued. Exit interview held and a copy of the report will be emailed to the program director.