Facility Evaluation Report

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management – Incident visit to the facility. LPA met with the Assistant Administrator Chary Hallon, and explained the reason for the visit. Today's visit is regarding a Special Incident Report submitted to the Community Care Licensing Division (CCLD). The incident, reported to have occurred on 10/16/2025, alleges that Staff #1 (S1) was witnessed by another staff intentionally tripping Client #1 (C1).

LPA requested copies of relevant documents related to the incident, including but not limited to: C1’s physician’s report, C1's Individual Program Plan (IPP), S1’s facility record, and written statements from staff who were present at the time of the incident. LPA interviewed the Assistant Administrator and two (2) staff. LPA attempted to interview one (1) of four (4) clients. Client #2 (C2) did not respond to LPA's questions. LPA was unable to interview C1 because they had left the facility and would not be returning today.

According to the Assistant Administrator, S1 denied they intentionally tripped C1 but ultimately decided to resign on 11/03/2025. The facility conducted an internal investigation and S1 was removed from the schedule on 10/19/2025. The facility found the staff that witnessed the incident credible however the other three (3) staff present that day stated they only witnessed C1 either falling or already on the floor and did not witness any staff involvement.