Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/28/25, stemming from incident report received on 8/1/25. LPA was greeted by Elizabeth Sandoval, Medication Aide, and the purpose of the visit was explained. Naylet Velazquez, Medication Aide/Second Designee, arrived shortly after to assist with the visit. Rosalie Sandoval, Executive Director, was contacted telephonically and was also informed about the reason for the visit.

According to Unusual Incident Report (SIR) received on 8/1/2025, licensee self-reported that a resident was having sexual contact with another resident in the facility which was witnessed by a staff member who then reported the incident to the director. The incident happened on 7/24/25 in the evening. According to SIR, the incident took place at the facility between Resident 1 and Resident 2 (R1-R2). R1, indicated to staff, R2 is their friend but felt pressured by R2 to receive sexual advances which made R1 feel uncomfortable.

LPA conducted interviews with Staff 1 – Staff 4 and obtained the following information: administrative staff have talked to R2 regarding the inappropriateness of their behavior toward R1. Staff are taking extra measures to supervise the interactions between R1 and R2. Staff are also conducting more frequent checks on R1 in their room and while spending time in the common areas of the facility to ensure R1's safety. Staff further indicated, R1 is safe and well taken care of by staff and no other incident has been witnessed or reported. Telephone interview with Ombudsman indicated that they came out to the facility to do a wellness check on R1 after the incident. Ombudsman indicated that the facility did everything they are supposed to do in this type of situation. Facility notified Ombudsman, licensing and R1’s conservator/responsible party about the incident.