Facility Evaluation Report

Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced case management visit in regards to a Serious Incident Report (SIR) received regarding Client #1 (C1) who sustained a fall and fracture. LPA met with Joan Cole, Direct Support Staff for the facility, and explained the purpose of the visit. Administrator Jourdan Sanvictores arrived shortly thereafter.

Per interview with Staff #1 (S1) and the SIR, C1 had been sitting on the edge of their bed when they had attempted to dress themselves, which caused them to fall and fracture their leg. C1 has been hospitalized and is currently in a Skilled Nursing Facility (SNF) since the incident to recover from the fracture.

LPA conducted a tour of the facility and also obtained the FACE Sheet, Individualized Program Plan (IPP), and Physician's Report for C1.

LPA will return at a later date to conclude the investigation. No deficiencies were observed during the visit. Exit interview held and a copy of the report was provided.