Facility Evaluation Report

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced case management visit to deliver investigative findings. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Carlos Montano and Director of Operations Cecilia Steinbach.

On 4/7/2025, the Department received a self-reported incident report regarding Client 1 (C1) and conducted a case management visit on 4/9/2025 to follow up on the incident. Review of C1’s Admission Agreement and medical records revealed that C1 was admitted to the facility on 3/26/2025 after being discharged from the hospital due to a suicide attempt which occurred in early March 2025 and resulted in C1 being hospitalized from 3/9/2025 to 3/26/2025. Review of C1’s pre-admission assessment documents revealed that C1 had a history of suicidal ideation (SI), a family history of suicide, and had a history of at least two prior suicide attempts. Assessment records noted that C1 had both pre-planned and spontaneous suicide attempts. Additionally, C1 reported experiencing suicidal ideation 2-5 times a week. Assessment records provided conflicting information regarding the severity of C1’s SI. C1 reported that suicidal thoughts ranged between fleeting, lasting only a few moments and lasting between 4-8 hours a day. Additionally, C1’s ability to control those thoughts varied between easily controlled and unable to control thoughts. C1 was assessed to be at serious risk of suicide harm. Interviews revealed that facility management and staff were aware of C1’s SI and past suicide attempts and were aware that C1 was at an increased risk of suicide.