Facility Evaluation Report

On July 31, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 7/13/25. LPA met with Program Director, Angel Carter and explained the purpose of the visit.

The Licensee reported, on 7/13/25, Resident 1 (R1) knocked on staff office and reported that he/she attempted to commit suicide. Staff observed R1 with a towel wrapped around his/her neck and blood stains. Staff immediately called 911 and R1 stayed in the staff office until paramedics arrived. R1 notified paramedics that he/she cut his/her neck with a razor blade and then layed in bed until reporting incident to staff. R1 was transported to the hospital. Staff later found alcohol, sleeping pills and a pocket knife hidden in R1's room. R1 was transferred from one hospital to another for medical stabilization and then was transferred to a psych unit.

During the visit, LPA reviewed R1's file and spoke to staff. R1 is no longer a client at the program as R1's treatment team decided to move her into a different facility so R1 can receive the level of care needed. According to the Program Director, this was R1's first time attempting to commit suicide since he/she has been a client at the facility. R1's treatment team indicated he/she had a history of attempting to commit.

Based on R1's file, R1 was admitted to the facility on 4/25/25 and has a history of drug use, trauma, violence and suicide attempts. The last suicide attempt R1 had was at a previous facility in December of 2024 where he/she had two incidents within two days. According to the Program Director and documents reviewed, when R1 was admitted to the facility in April 2025, R1 saw his/her behavioral health therapist once a week, saw his/her case manager once a week, saw his/her psychiatrist once a month or as needed. The facility was continuing to monitor R1's symptoms and report it to R1's treatment team. The facility also has a counselor on site all day to talk to R1 when he/she needed to discuss feelings. Facility conducts room searches when there clients are suspicious and/or randomly, however according to the staff, R1 presented very well. Room checks are being conducted daily.

No citations are issued during the visit. Report is reviewed with Program Director and a copy is provided.