Facility Evaluation Report

On 01/23/26 Marcela Yanez conducted an unannounced case management visit to deliver findings on an investigation. LPA announced the purpose of the visit and met with Frank Ebo, Designated Administrator. Administrator was reached by phone regarding visit.

On July 17, 2025, the department received an incident report regarding an altercation between a previous client and a current client that occurred on July 16,2025.

During the investigation the department interviewed 4 staff and 2 clients. S1 stated that during his/her shift a previous client (C3) arrived at the facility and was agitated and began fighting with 2 current clients (C1 and C2). S1 who was in the medication room of the facility, and the only staff on shift, was watching the monitors that display video surveillance of the facility premises and observed C3 arrive at the facility.

S1 stated he/she asked C3 to leave the facility C3 left but then returned on 2 different occasions the same night of incident but returned a third time. C3 left the facility but shortly returned at 7:58 PM. C3 was observed walking towards the client’s bedroom. S1 called local law enforcement and was on the phone with dispatch when he/she saw C3 attack C2 in the hallway. S1 remained in the medication room on the phone with local law enforcement while C2 was being attacked. After C3 attacked C2, C3 walked to the courtyard and attacked C1. S1 stated that he/she observed the resident being attacked through the enclosed medication room window which faces the courtyard S1 stayed in the locked medication room during the whole incident until C3 left the facility.