Facility Evaluation Report

Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced case management visit at this facility to follow up on the incident occurred on 04/07/26 at 7:10pm, wherein Client #1 (C1) reported that he/she had been sexually assaulted while lying in his/her bed in her room. LPA met with Administrator, Executive Director, and Clinical Director and explained the reason for the visit.

LPA conducted a physical plant tour at 11:10 AM, requested copy of facility documents at 11:15 AM, reviewed records between 11:20 AM to 11:25 AM and interviewed the Executive Director between 11:30 to 12:00 PM. During interview, the Executive Director stated that C1 was admitted to the facility on 04/06/2026 from another facility. Since admission, C1 reportedly expressed a desire to leave the facility. LPA was informed that C1 met with multiple clinicians in an effort to identify the reasons for wanting to leave, and resources were offered to support C1. The Executive Director stated, “The facility was made aware of C1’s pattern of transferring through several facilities where C1 was admitted for only a couple of days and left without completing rehabilitation.”

Regarding the reported incident on 04/07/2026, facility staff reported that C1 disclosed being sexually assaulted; however, C1 did not provide identification of an alleged perpetrator, a specific time of occurrence, or additional details regarding the allegation. Shortly after making the allegation, C1 informed staff of his/her intent to leave the facility Against Medical Advice (AMA) and departed the facility prior to further assessment or follow-up. Facility staff contacted law enforcement regarding the allegation. Officers advised that an investigation could not be initiated at that time due to C1 no longer being present at the facility and the limited details available. Law enforcement further indicated that any additional investigation would require direct reporting from C1. Continue on LIC809-C