Facility Evaluation Report

Licensing Program Analyst (LPA) De Leon conducted a case management incident report visit to the facility above. LPA met with Raneile Jeffers and explained the purpose of the visit.

The facility Administrator called the department On Duty Officer (OD) of the day to report an incident with client at the day program on 06/15/2026. Administrator followed up with a written incident report on the same day to the department on 06/15/2026. The incident involved client 1 (C1) was supervised by staff with a 3:1 ratio, Staff 1 (S1) had to use the restroom and asked the other staff to watch the 3 clients, the staff said okay and S1 used the restroom for about 3-4 minutes, when S1 returned to the client group C1 was missing, S1 asked other staff present and staff did not know where C1 went. S1 noticed the back door open, S1 proceeded out the back door and found C1 down the stairs on the ground with C1's wheelchair upside down and C1 face down, C1 postural support chest strap was in place. C1 was able to undo C1's seat belt and asked staff to help get the wheelchair off C1. S1 asked C1 if C1 was OK and C1 replied "I'm OK I rolled down the stairs". S1 called Administrator whom immediately called 911, S1 removed strap and wheelchair from C1 and noticed a large softball size scrape on he top of C1's head with blood present, S1 applied pressure to C1's scrape and assessed the area, C1's nose was bleeding from the right nostril and there were no signs of any other injuries. C1 was transported to Sierra Vista Regional Hospital. C1 was discharged the same day with a broken pinkie finger and 2-3 stiches on the top of C1's head and some torn ligaments in C1's knee. C1 was able to return to program on 06/18/2026 within 3 days of the incident. The day of the incident the facility was fully staffed and meeting all ratios for staffing unfortunately when S1 went to the restroom S1 should have called for another staff that was not with clients to sit with the clients while S1 was using the restroom. Staff have had additional training and have requested a 1:1 ratio for C1 while at program from Tri-Counties Regional Center (TCRC).

The facility will keep eyes on C1 at all times until C1 is approved for a 1:1 ratio at day program.

Exit interviewed conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights printed for administrator.