Facility Evaluation Report

At approximately 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Clinical Director, Nancy Lambert, and Administrator, Charlie Litchfield . The purpose of today's visit is to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 07/09/2025. Report stated that on 07/03/2025, Client 1 (C1) jumped the facility fence, ran away, and removed their ankle monitor. Report further states that a missing person report was filed and on 07/08/2025, facility was notified that C1 was located and admitted to a Crisis Stabilization Unit. Facility made all appropriate notifications per regulation.

LPA requested documentation. Review of C1's physician report states that C1 is unable to leave facility unassisted. Review of additional paperwork revealed that C1 was unable to leave without supervision due to being under court order and not for a medical reason.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.