Facility Evaluation Report

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-incident regarding an incident which occurred where client (C1) seen attempting to wander towards the facility parking lot area. LPA Monter met with Administrator Caroline Mayo(ADM) and stated the purpose of today's visit.

On February 28, 2025, the Department received an incident report, regarding resident R1, which stated the following. On February 28, 2025, around 10 AM, R1 left the building; however staff promptly intervened. A staff member encountered him/her as he/she was walking out the doors, but R1 ignored and continued to walk towards the gate. Despite being instructed to return inside, R1 proceeded to walk towards a staff member's car. Staff needed a few minutes to redirect R1 back inside the program.

On June 25, 2025, LPA interviewed ADM. ADM stated R1 gets attached with staff and will not listen to staff if he/she doesn't like them. ADM stated R1 did get a 1 on 1 care staff the following month. ADM stated since then, R1 has not had any issues. ADM stated staff has been oriented regarding R1's behaviors and anyone that would be responsible for R1's supervision, is aware of his/her behaviors.

ADM stated regarding this event, This was the first time R1 had exhibited this behavior. ADM stated since then, R1's 1 on 1 has been implemented and there has been no issues.

Exit interview was conducted with Administrator Caroline Mayo. No deficiencies cited.