Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted an unannounced Case Management Visit-Incident on 8/8/25, stemming from incident report received on 7/1/25. LPA was greeted by Edyssa De Leon, Direct Support Provider, and explained the purpose of the visit. Licensee, Edith Williams arrived shortly after to assist with tour and facilitate record review.

According to Unusual Incident Report received on 7/1/2025, staff self-reported that Client 1 (C1), experienced a sexual assault while out in the community on 6/30/25. C1 returned home the same day and reported the incident to staff. Administrator, transported C1 to the hospital to get checked. Police were contacted by a social worker and police arrived to interview C1 during the hospital visit. Administrator returned to the facility and was present when police dropped-off C1 at the home the next morning after the incident.

LPA conducted interviews with staff and obtained the following information: Licensee and Administrator indicated during interviews, C1 is independent and is accorded autonomy which includes going out into the community unsupervised per Individualized Program Plan (IPP) goals and C1's current capabilities. Staff stated, after the incident, staff have come to an agreement with C1 to have a staff accompany C1 on their trips to the community, to which C1 has agreed. Record review of C1’s IPP held on 3/1/25 indicated, C1 is allowed to go to school independently and to conduct other activities in the community on their own accord.