Facility Evaluation Report

Licensing Program Analyst (LPA), Mayra Cota, conducted a Case Management – Incident visit today to follow-up on two (2) Special Incident Reports (SIR) received by the department. LPA, met with Jacqueline Cortez, Executive Director, and the reason for the visit was explained.

According to the first SIR, date of occurrence 10/19/2025, a staff member (Staff 3/S3) raised their voice and made an inappropriate comment to a resident (Resident 1/S1) during an encounter in which R1 requested help. R1, reported the incident to the Executive Director (Staff 1/S1) and Care Coordinator (Staff 2/S2).

According to interview with S1, S1 spoke to S3 to remind them that residents need to be always spoken to calmly and with respect. S1 stated that, S3 admitted to raising their voice and making inappropriate comment toward R1. S1 indicated that S1 and S2 assessed R1 after the incident and did not observe any injuries and R1 continued their normal routine the rest of the day.

S1 indicated that S1 talked to S3 on 10/31/25 regarding the incident, and a formal meeting and write-up regarding professional conduct and resident standards took place on 11/12/25. During this meeting, the written notice was discussed and provided by S2 to S3. Interview with S2 indicated that S3 has been taken off assignment of R1’s room and is not allowed to enter R1’s room at any time. S2 stated that they monitor the assignments and ensure that S3 does not interact with R1. Interview with R1 indicated that S3 is not coming into their room anymore and is glad that staff were proactive after R1 reported the incident.