Facility Evaluation Report

Licensing Program Analysts (LPAs) Michelle Echeverria and Becky Mann conducted an unannounced case management visit to follow up on an incident report sent to licensing on 11/11/25. LPAs introduced self and stated the purpose of the visit to Assistant Administrator, Dameon Lester.

During today's visit, LPAs performed a health and safety check, review records and interviewed Dameon to discuss the incident and surrounding events. LPAs discovered that client 1 (C1) was hospitalized and arrested due to an incident that occurred at a nearby park with law enforcement. LPAs also discovered during record review that C1's IPP stated that due to refusal to work or attend day program, C1 was receiving 150 hours per month of 1:1 supplemental support in lieu of a day program. The service was divided into approximately 6 hours per day, M-F meaning that it would be from 8am-2pm. According to the incident's date and time, C1 should have been with their 1:1 staff as specified on their IPP report. The facility neglected the needs of C1 and did not provide the care and supervision required.

A deficiency and a civil penalty were issue during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC421IM and appeal rights were discussed and then provided to Assistant Administrator, Dameon Lester.