Facility Evaluation Report

On 04/14/2025 at 8:00am, Licensing Program Analyst, LPA Zina Brown conducted a Case Management visit to follow up on the incident reported for Client #1 (C1) and Client #2 (C2). LPA was greeted by Anna Marie Peji, Assistance Adminstrator . LPA explained the purpose of the visit was to gather information surrounding incident of assault between Client #1 (C1) and Client #2 (C2) that occurred on 04/09/2025 approximately at 03:46pm.

The regional office received unusual incident/injury report from the facility who reported the assault between Client #1 (C1) and Client #2 (C2) on 04/09/2025. The incident report stated that Client #1 (C1) assaulted Client #2 (C2). According to the incident report (C1) is currently in police custody while Client #2 (C2) was transported by 911 to St. Mary Medical Center – Long Beach for laceration on the scalp.

At 8:10am, LPA requested the following documents:

· ID and Emergency Information (dated: 02.08.2024 for C1 and 01.05.2009 for C2)

· Admission Agreement (dated: 02.08.2024 for C1 01.01.2024 for C2)

· Physician Report for Community Care Facilities LIC 602A (dated: 01.13.2025 for C1 01.14.2025 for C2 )

· Preplacement Appraisal Information LIC 603 (dated: 02.08.204 for C1 06.06.2024 for C2 )

· Medication Administration Record (MAR) for the month of April 2024

· Staff Roster (dated 04.14.2025) & Client Roster (provided on 04.14.2025)

· Video Footage of the Incident (occurred on 04.09.2025) emailed to LPA on 04.14.2025 at 8:56 am

An exit interview was conducted with Anna Marie Peji, Assistance Administrator and a hard copy was provided.