Facility Evaluation Report

At 09:40 a.m. on 02/10/2025, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced case management visit to this facility. LPA Casillas met with Quality Assurance (QA) Andrea Messina from North Los Angeles Regional Center at the facility. LPA and QA met with the Administrator Linda Hughes and disclosed the reason for the visit.

LPA and QA were greeted by staff member and were granted access. Entrance interview conducted.

Today’s case management visit is to follow up on an incident previously reported on 02/04/25 by the facility in which clients and staff members were locked out of the facility due to the security screen being locked and no one having a key. Client #1 (C1) offered to enter the facility through a bathroom window that was not locked and with assistance C1 was able to reach the window and proceeded to enter the facility. Once C1 was midway through the window C1 gave the ok to be released, it is then that C1 lost their balance and landed in the bathtub. C1 expressed that C1’s left arm was injured. Staff checked C1’s arm and there were no signs of redness, bruising, or swelling. Per the SIR, C1 was given an ice pack and went to lay down. A few minutes later C1 continued about their day expressing mild discomfort. The following day, C1’s arm displayed swelling and bruising and staff proceeded to take C1 to the emergency room where C1 was diagnosed to have fractures. The purpose of the visit is to obtain additional information regarding this incident.