Facility Evaluation Report

At 9:40 Am, Licensing Program Analyst (LPA) Mariana Agban conducted a Case Management–Incident visit at the facility. Upon arrival, LPA met with Staff #1 (S1) and contacted Administrator Natasha Ocha, who stated that she was currently on leave since February 3rd, 2026. The Administrator advised that Administrator Designee Jessica Hately would be present at the facility. The Administrator Designee arrived at approximately 1:10 p.m. The Regional Director was present at the facility beginning at approximately 10:00 a.m. At 9:45 a.m., LPA conducted a physical plant tour to ensure that clients’ health and safety were protected. During the tour, LPA observed that only one staff member (S1) was present on the premises with two clients. LPA requested copies of the Personnel Report, staff schedule, Client Roster, and the Administrator Designee’s file. LPA was provided with an outdated Personnel Report dated 09/03/2024 and a Client Roster dated 08/18/2019. LPA was informed that no physical personnel file for Administrator Designee Jessica Hately was available at the facility. The purpose of the visit was to follow up on three Special Incident Reports (SIRs) submitted by Administrator Natasha Ocha reporting that Client #1 (C1) was absent without leave (AWOL) from the facility. LPA conducted a file review of Client #1’s records and observed that the Preplacement Appraisal, Functional Capability Assessment, Appraisal/Needs and Services Plan, and Physician’s Report were incomplete. At this time, LPA is unable to conclude the investigation, as additional information is required.

An exit interview was conducted. Citations issued, appeal rights were provided, and a copy of this report was delivered.