Facility Evaluation Report

Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to follow up on a suicide attempt incident report involving Client #1 (C1) on November 1, 2025. LPA met with Administrator Laura Palomino and explained the purpose of the visit. On today's date, LPA conducted two staff interviews, inspected the medication, and obtained the following records: Face Sheet, Resident House Rules, Individual Program Plan (IPP), Client Development and Evaluation Report (CDER), Physician's Report, Health & Physical (H&P), Daily Progress Notes, Medication Administration Record (MAR) for November 2025, medication orders, Client Personal Property and Valuables, and Program Design.

C1 was admitted to the facility on October 16, 2025 and was placed on a 30-day trial ending on November 16, 2025. On November 1, 2025, approximately 5pm, C1 attempted suicide in their room by ingesting four bottles of medications that C1 had brought from their prior residence. C1 was immediately admitted to the hospital for treatment and was subsequently transferred to a second hospital on an involuntary psychiatric hold. C1 has not returned to the facility since.

Based on an interview with Admin Palomino, minimal information was obtained from C1's social worker and the regional center. The IPP and CDER was not current both dated October 24, 2023. Admin stated that they were not informed if C1 had other prior history of suicide attempts and was unaware per interview C1 having prior suicidal ideations which was documented on page 8 of the IPP. However, there were no documentation of prior suicide attempts per the CDER and IPP. Based on the review of the Program Design, page 15 indicates that when a client moves in, Admin stated that staff will walk through and inventory all personal belongings the day client moves in. Admin stated that facility was unaware that the four medications were in possession of C1.