Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conduct a case management health and safety check on an incident report submitted to the Orange County Regional Office on June 26, 2025. LPA was greeted and granted entry by staff. LPA met with House Manager (HM) Matilde Ventura and explained the purpose of the visit.

The incident report submitted to the Orange County Regional office stated that on June 24 th , 2025 the day program staff emailed the Administrator about bruising on Client #1s (C1) arm and thigh. Interviews revealed that Staff #1 (S1) informed day program on June 23 rd , 2025 of the bruising after it was found in the afternoon of June 20th, 2025. S1 informed LPA that they gave C1 a body check before leaving for day program on June 20 th , 2025 and no bruising was found. Staff #2 (S2) observed the bruising when doing a body check on C1 after returning from day program on June 20 th , 2025. LPA reviewed a body check sheet for the month of June for C1 that revealed S1 did not find bruising in the morning of June 20 th 2025, but S2 found bruising in the afternoon of June 20 th , 2025. LPA reviewed the communication book between the facility and the day program and it was revealed that the facility and day program did not notate a bruise on June 19 th 2025 or June 20, 2025. S1 notated that there was bruising found in the communication book with day program on June 23, 2025 and that an RN was notified. LPA observed notations of C1 with self-inflicting behaviors such as scratching, pinching and hitting in the communication book. LPA observed C1s bruising on the outside of their left arm and left thigh. LPA observed C1 thrashing in their wheelchair and walk with an unsteady gait. LPA observed C1 run into the corner of the wall when ambulating.

Based on today’s visit there are no health and safety concerns. An exit interview was conducted with HM Matilde Ventura and a copy of this report was left at the facility.