Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Incident on 03/24/2026. LPA was greeted by Administrator Lladira Perez and explained the purpose of the visit.

On 12/19/2025, LPA Ramirez received a General Event Report (GER) and blank Report of Suspected Dependent Adult/Elder Abuse (SOC 341) for client#1 (C1). According to this report, on 12/17/2025, at approximately 2:15 pm, AM and PM staff were in the living room. Before shift change C1 had clothes in the washing machine and clothing in the dryer and was waiting for their laundry to be done. S1 entered the kitchen area asking about the popsicles that they left in the freezer. S1 asked who ate a popsicle because S1 had three but now there were only two popsicles left. C1 ate a popsicle. S2 then stated “of course C1 ate it because C1 big size. C1 is extra large. S1, S2 and S3 laughed out loud. After staff were done laughing, S2 pointed at C1’s pants and said, ugh you pissed your pants, pee pee pants. C1 started pulling their shirt down and became defensive and explained that their clothes were still in the dryer. On 12/19/2025, S2 was relocated to another home pending an internal investigation.

On 12/31/2025, the facility completed an internal investigation which revealed the following: On 12/18/2025, S4 contacted the facility Human Resources Director to report two incidents involving the safety and well-being of C1 and C2. Both incidents occurred on 12/17/2025. S4 reported that they personally witnessed S2 use bullying and demeaning language towards C1 after C1 urinated on themself. S4 stated that S2 mocked and belittled C1 by referring to C1 as pee pee pants and openly questioning why C1 pissed themselves. S4 also reported that S2 made remarks about C1 weight and size after S2 was unable to locate their popsicle.