Facility Evaluation Report

On 09/03/25 Licensing Program Analyst (LPA) Javina George made an unannounced case management incident visit to the facility. The LPA met with Administrator Brianda Munoz, and explained the purpose of the visit. An Unsual/Injury Incident report was received on 09/02/25, regarding client #1 (C1) exhibiting self injurious behaviors. C1 is currently out of the facility, and LPA was unable to conduct an interview with C1.

During today's visit LPA conducted interviews with administrator, and responsible party. LPA observed for staff to have removed items from C1s room such as mirrors, decorative items (metal flower), pencils, pens, and shoe laces. Additionally, LPA conducted a records review of C1s file and observed for C1 to not have a medical assessment completed prior to be admitted to the facility. Deficiency cited .

An exit interview was conducted where a copy of this report, 809D, appeal rights, LIC811-Confidential names list were reviewed and provided to Brianda Munoz, administrator.