Facility Evaluation Report

On September 23, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on an incident that occurred on September 11, 2025. LPA met with Program Manager, Maria Villacorta and explained the purpose of the visit.

The Licensee reported, on September 11, 2025, Resident 1 (R1) was eating snacks while staff and other clients were playing bingo. R1 mistakenly ate a binge marker/marble thinking it was a cookie. It was too late for staff to stop R1 from swallowing the bingo marker/marble. 911 was called and R1 was taken to the hospital.

During the investigation, LPA interviewed the Program Manager, staff, and reviewed R1's file. According to R1's file, R1 has a diagnosis of dementia and is confused/disoriented. According to interviewed staff, R1 has never swallowed objects in the past and this was the first time this type of incident occurred. R1 was observed to seem fine and returned back to the program the following day. Program Manager and staff interviewed indicated R1 did attempt to swallow a connect 4 chip the following week, but staff immediately stopped him/her. LPA requested to see R1's discharge notes from September 11, 2025, however the facility did not have a copy. LPA advised Program Manager to update R1's care plan.

No citations are issued during the visit. Further investigation is required. Report is reviewed with Program Manager and a copy is provided.