Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to conducted case management visit. LPA met with Staff, Maria Medina, who was informed of the purpose of the visit.

LPA conducted clients, staff interviews, and records review. It was revealed a week prior to 08/13/2025, there was an incident involving where Client #1 (C1) was hit by another client. No incident report was documented for C1 or submitted to the licensing agency. Based on client and staff interviews C1 was not seen by a medical professional for their injuries, conflicting information was provided with staff stating the client did not sustain injured however client revealed C1 hit their head on the wall. It was also revealed C1 called police due to the altercation. Therefore, a deficiency is issued for reporting requirements as the reporting window of (7) days has passed.

An exit interview was conducted and a copy of this report, deficiency page, and appeal rights were reviewed and provided.