Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit- Incident on 02/03/2026. LPA was greeted by Administrator Russell J Johnsrud and explained the purpose of the visit. Facility Quality Assurance Director- Claudia Lujan arrived shortly after to assist.

On 01/23/2026, LPA Ramirez received a Vendor Special Incident Report that revealed the following: on 01/22/2026 at approximately 1:15pm, Staff#2 (S2) arrived at the facility 45mins before their scheduled shift and heard client#1 (C1) screaming. Upon entering the facility, S2 observed S1 seated at the staff desk located in the kitchen area, using their phone. S2 observed the bathroom door closed and C1 was heard screaming from inside the bathroom. S2 entered the bathroom and saw C1 seated on the toilet and was not wearing clothing. S2 did not observe C1’s clothing inside the bathroom. S2 observed C1’s PJ’s on the outside of the bathroom near a countertop that is located near the bathroom door. S2 asked S1 why C1 was not wearing any clothing. S1 allegedly told S2 that they were waiting for C1 to stop screaming before handing C1 back their clothing. S1 handed C1 their clothing and C1 dressed themselves in the bathroom. Staff conducted a body check on C1 and did not note noticeable injuries.

LPA Ramirez conducted two staff interviews and gathered additional documents. Due to time constraints, additional interviews and review of documents are required. No deficiencies were made during this visit. LPA Ramirez will return at a later day to complete this visit.