Facility Evaluation Report

Licensing Program Analyst (LPA) Loera arrived unannounced to deliver findings related to a self-reported incident received by CCL on 7/15/2025. LPA met with Administrator, Sheri Lott.

On 07/14/2025, Client (C1) was observed laying on the ground in the backyard. C1 reported they had been doing dishes and watching a show prompting them to go to the balcony and jump off. There were no staff in the area at the time C1 jumped. C1 reported to emergency medical services (EMS) personnel that they jumped from the balcony purposely trying to hurt self. C1 had suicidal ideations in the past and reported they usually had these urges to jump but speaks to staff who help intervene before C1 did anything. At the time C1 jumped from the balcony, only one staff was present (although no staff in the area) with 4 clients at the facility. According to staff (S1), the facility requires that two staff be present. C1 was taken to the hospital and was diagnosed with a closed unstable burst fracture of third lumbar vertebra and left foot fracture.

Current and former staff reported that C1 made multiple attempts to jump off the balcony prior (3/31/2025) to 07/14/2025 fall. There was no alarm on the balcony door when C1 jumped off the balcony. C1 had suicidal ideations and the facility failed to implement a risk plan to prevent C1 from trying to jump off the balcony.

Based on the Departments interviews and records obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED .

Neglect/Lack of Care resulted in violation causing injury to person in care $500 immediate civil penalty issued.