Facility Evaluation Report

On 5/12/25 Licensing Program Analyst (LPA) M. Garza arrived to complete an unannounced case management visit. LPA met with Program Manager, Kelly Wheeler and Program Manager, Isabelle Gonzales explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on clients in care. Clients were observed in activities areas.

This case management is being conducted due to an incident that occurred on 5/9/2025. An Special Incident Report was received from the facility stating Client #1 (C1) swallowed clay during activity. EMS was contacted.

During visit review of documentation (physicians report, IPP, physiologic evaluation, social assessment) and completed interviews. C1's file reflected a physicians report that was dated 10/21/2005. IPP was dated 7/24/24 and does not mention C1 having PICA. During interviews it was disclosed that C1's responsible party informed staff that "this occurs often". C1's file does not reflect this change in condition. Deficiency cited per Title 22.

Exit interview completed with Program Managers, Kelly and Isabelle. A copy of this report, deficiency and appeal rights provided.