Facility Evaluation Report

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit. LPA was greeted by and met with Lead RBT Cassandra Eversole and Administrator Natasha Stutzman, to discuss the purpose of the visit.

Today's visit is in response to the facility's self-report of an elopement by Client 1 (C1) with an unauthorized hold, and an elopement by Client 2 (C2). Staff interviews and records showed that on 06/01/2026 C1 experienced a behavior episode and advanced beyond the delayed egress gate, reaching close to the edge of a drop-off. Staff involved in the incident informed that three (3) staff conducted a hold which was reserved for four (4) people, due to the severity of the situation. Staff informed that during the incident while C1 was advancing toward the edge, an oncoming car was visible and no other holds were possible or would have been effective in the moment. C1 sustained redness and scratches due to lying on the ground and scooting down the hill toward the edge. Due to the potential danger of C1 increasingly attempting to advance beyond the delayed egress door, the facility is considering having the delay time increased from 15 seconds to 30 seconds. Regarding C2, they experienced a behavior episode early morning of 06/02/2026, resulting in an elopement. Staff stayed with C2 and were able to redirect them back into the facility without utilizing a hold and with no injuries.

LPA conducted a wellness check at the facility; no health or safety issues were identified. A Technical Violation was issued regarding an unauthorized hold per California Code of Regulations Title 22. An exit interview was conducted with Administrator Natasha Stutzman, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.