Facility Evaluation Report

On December 10, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit in relation to an incident that occurred on 11/20/25. LPA met with Resident Care Coordinator, Rose Ruiz and explained the purpose of the visit.

The Licensee reported on 11/20/25, Resident 1 (R1) bit into a bar of hand soap. Caregivers assisted in washing it out and giving R1 water. R1's lip was swollen. Poison control was contacted and R1's responsible party and physician was notified. R1 was in the communal area for observation.

During the visit, LPA reviewed R1's file and discussed the incident with Resident Care Coordinator. According to the Resident Care Coordinator, R1 has a roommate, Resident 2 (R2) who's family member brought in the bar soap and placed it in R2's cubby without notifying staff. According to R1's file reviewed, R1's physician's reports dated 3/5/25 indicates that R1 has a dementia diagnosis, however is not at risk if allowed direct access to personal grooming and hygiene items. According to R2's physician's report dated 10/3/25, R2 has a dementia diagnosis and is at risk if allowed direct access to personal grooming and hygiene items. Resident Care Coordinator indicated that R2's responsible party was informed about the incident and was notified that if chemicals/hygiene products are being brought into the facility, it needs to be locked in the storage room by staff.

Based on records reviewed, this is the first time R1 has shown at risk behaviors if he/she has access to personal grooming items and hygiene items. R1's service plan was updated to show R1 is at risk if allowed access to hygiene items.

No citations are being issued during the visit. Report is reviewed with Resident Care Coordinator, Rose Ruiz and a copy is provided.