Facility Evaluation Report

Licensing Program Analyst (LPA) Becky Mann visited the facility unannounced for a case management visit. This case management visit is in response to a voicemail from Administrator about the incident on the Office Duty Line on July 3, 2025 from the facility. LPA met with Sherry Esquillo, House Lead and explained the purpose of the visit.

The Special Incident Report (SIR) documented that on June 26, 2025, Staff #2 (S2) and Staff #3 (S3) contacted Administrator about Staff #1 (S1) who had abruptly had an outburst at the facility. S1 started screaming. Client #1 (C1) was in the kitchen at the time of the incident. LPA made a few attempts to ask C1 about the incident but they were unable to answer the questions.

During today's visit, LPA discussed the incident and the surrounding events. LPA interviewed staff and clients and conducted a record review. No health and safety concerns were discovered, and the investigation into this incident is closed .LPA randomly reviewed client files for Physicians Report and discovered that 2 of the clients do not have Tuberculosis results.

Deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and a copy provided to Sherry Esquillo, House Lead.