Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit due to an incident reported on 12/13/2022. LPA was greeted and granted entry into the facility by Ruby Leyva, Mental Health Technician. Administrator Gregory Rosenbaum arrived at 10:20 AM.

The department received an Unusual/Serious Injury Incident reported dated 12/13/2022 for an incident that occurred on 12/11/2022. It was reported that Client 1 (C1) checked out a razor to shave themselves. C1 reported that they had cut themselves on their face and finger, C1 was given a Band-Aid and ointment. C1 requested another razor to finish shaving, sometime later C1 reported that they had made horizontal cuts to their forearms. C1 reported they did not have suicidal ideations. Facility Nurse performed a body check and noted no other cuts were made. Clinical assessment was performed on C1 and it was determined no other preventative actions needed.

Per Administrator Gregory Rosenbaum, C1 was placed on 15 minute checks and staff searched C1's room for other sharps. C1 successfully discharged out of the program on 12/22/2022.

During the visit LPA reviewed and obtained copies of Admission Agreement, Initial Psychiatric Evaluation dated 09/26/2022 and copies of body check consent form.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.