Facility Evaluation Report

Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced CASE MANAGEMENT-INCIDENT visit to this facility and met with Administrator, Lora Pana.

On August 18, 25, Community Care Licensing (CCL) received Unusual Incident Reports indicating that during a facility outing to the park, R1 jumped into the lake, causing scrapes on R1's right and left knees. On September 7, 2025, CCL received another report stating that during a different outing to another park, R1 again jumped into the lake, resulting in an abrasion on R1's right knee. During today's visit, LPA interviewed the facility Administrator and Staff #2 (S2) regarding the incidents. The administrator stated that R1 has always been supervised by a 3-1 staff-to-resident ratio when out in the community. The administrator also mentioned that staff will avoid taking R1 to places with bodies of water where R1 could jump in. LPA obtained copies of R1's IPP, Quarterly Progress Report, Personnel Report, and Client Roster. During the file review, LPA observed that no assessment or plan of action had been created to prevent future incidents. LPA advised the administrator that a plan of action must be in place to prevent future incidents. In addition, LPA advised that facility personnel shall be competent to provide the necessary services to meet individual client needs

Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.