Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Lauren Cottman. The purpose of the visit was to follow up on a SOC341 report that was submitted to Community Care Licensing (CCL) on 1/23/26. Per SOC341, on 1/21/26 at approximately 6:30pm, resident (R1) approached resident (R2) touched their shirt, R2 verbalized their dislike and shoved R1 to the floor causing them to hit the back of their head. They were immediately separated by staff. EMS initiated and assessed R1 for injury, R1's responsible party declined transport. Both residents have been placed on alert charting for 48 hours. R2's care plan has been updated. Responsible parties were notified. During today's visit, LPA reviewed resident's records. Based on records review, R2's physician report dated 9/25/24, R2 does have a cognitive condition, but they don't have a history of aggressive behavior. Although, R2 receives frequent visits from a third party agency who indicated in their log dated 11/13/25 that they have noticed some concerns including behaviors and recommended further discussion with R2's responsible party before making any adjustments to antidepressant, which it was reflected in R2's 90-day care plan assessment dated 12/10/25. According to care plan, R2 has active behavioral issues requiring staff to be alert to triggers that could increase behaviors such as noise or crowded areas. On 1/22/26, the facility implemented a behavioral engagement log to identify any trigger situations to obtain more data, one-on-one engagement walks and outing were incorporated to help the resident with behavior issues. Additionally, R2's physician have made adjustments to some of R2's medications. According to Administrator, care plans were not updated for any of the residents because they have implemented the behavioral engagement. Regarding R1, LPA learned that the facility staff called the paramedics 911 immediately, they arrived, assessed R1 and they did the vitals, and reported to R1's responsible party who denied to transport R1 to the hospital for further evaluation. Based on records review and interviews, the facility have followed their protocols. No deficiencies were cited during today's case management visit. Exit interview conducted with the Administrator and copy of this report was given.