Facility Evaluation Report

On 02/11/2025, Licensing Program Analyst (LPA) Jaime Vado, conducted an unannounced case management visit in response to an incident report that was received on 02/10/2026. LPA met with administrator Lilibeth and explained the purpose of today's visit.

LPA discussed the details of the incident report received in regards to the suspected physical abuse the client may have received from a staff member. The incident indicated that around 1:30am on 02/07/2025 the client was in the bathroom with a staff member (Staff 2) and there were loud sounds coming from the bathroom. Later the same morning around 1:40am staff saw possible signs of alleged abuse. At around 6:50am, the client and Staff 2 were in the room of the client where more yelling was heard from Staff 2. Per interviews conducted, documents received, and photos reviewed, the client has skin issues and other behaviors that can cause skin issues such as excessive rubbing, and scratching of the face and shoulders. Based on interviews conducted, staff 2, was heard by at least 3 other staff yelling at the client on the same day of 02/07/2026 in the morning hours. A 4th staff has also reported that Staff 2 was heard yelling at the client in the past from within the clients bedroom. There were no witnesses to any physical violence as the client and Staff 2 were in the bedroom of the client. LPA received copies via email of pertinent documents related to the skin conditions and behaviors of the client as well as photos regarding skin conditions over time due to behaviors including the day of 02/07/2026.

A citation is being issued on the following LIC809D in regards to Staff 2's yelling at the client in care, which poses an immediate health and safety risk to resident in care.

Report is reviewed with the administrator Lilibeth Letrondo and a copy is provided on this day.