Facility Evaluation Report

Program Analyst (LPA) Simi Rai conducted an unannounced Case Management - Incident visit in regards to an Incident Report the Department received on 7/16/2025. LPA met with Interim Executive Director (ED) Brenda Ritter and stated the purpose of the visit.

On 7/16/2025, the Department received an LIC 624 Incident Report stating resident (R1) reported hearing 2 staff yelling at a resident in the hallway. R1 was not able to identify the 2 staff and 1 resident involved.

During today's visit, LPA Rai conducted interviews with 4 staff (S1-S4). Four out of the four staff stated they have not seen or heard staff yell at the residents or R1. Four out of four staff stated other residents have not notified them of staff yelling at residents.

During today's visit, LPA Rai conducted interview with 1 resident (R1). R1 was not able to provide information about when the incident occurred and who was involved, both the staff or residents. R1 was not sure if the 2 "staff" members were individuals that worked at the facility or if they were visitors. R1 was not able to recall if the 2 "staff" members wear a light blue shirt, which would indicate if they were staff working at the facility.

Based on review of R1's Physician Report dated 8/18/2021, R1 does not have neurocognitive disorders and R1 is able to manage own prescription medication and leave the facility unassisted. Based on review of R1's Service Plan dated 7/9/2025, R1 requires minimal assistance at night.