Facility Evaluation Report

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Case management incident visit to follow up on an incident that occurred on 5/10/2026. LPA met with Designated Administrator (ADM) Johannes Schlitz and Administrator (ADM) Daniel Lustre LPA stated the purpose of the visit.

On 5/12/2026 the Department received a Special Incident Report (SIR) for an incident that occurred on 5/10/2026. Per the SIR, on 5/10/2026 Designate ADM was informed by Staff, that a client, referred to as C1, "had ingested approximately 5-10 tablets of Advil 200 mg while in a community vehicle following a beach outing." C1's responsible parties were notified, including poison control. C1 was monitored for side effects. Per the report, C1 returned to baseline and had minor side effect of an upset stomach.

On 5/12/2026 LPA Tarin called and spoke with Designated ADM regarding the incident. During the call, LPA requested pertinent documentation to be submitted to the Department by 5/13/2026.

During today's visit, LPA interviewed 3 Staff, and 1 Client. Designated ADM provided LPA with the documentation requested on 5/12/2026. During interviews, Staff S3 stated after a facility beach outing on 5/10/2026, C1 appeared 'stressed' upon returning back to the facility. S3 stated C1 entered the facility, then walked back out to the facility vehicle. S3 stated he/she followed C1 to the vehicle. S3 stated C1 did not want to exit the vehicle. S3 then walked to get another staff, and upon returning to the vehicle, S3 saw C1 place something in his/her mouth. S3 stated he/she had inadvertently left a bottle of Advil in the facility vehicle lock box (glove compartment) on 5/10/2026. S3 states facility management was informed of the incident.