Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Stephanie Silva Santos.

The purpose of the visit was to follow up on incident reports submitted by the facility, including:

- On 04/17/2025, the facility reported that on 04/16/2025 a facility van was involved in an accident while residents were in the vehicle. (Note: an internal investigation conducted by the facility identified the driver of the van as staff S1.)

- On 06/03/2025, the facility reported that on 06/02/2025, a staff reported that on 04/02/2025, two staff consumed marijuana in front of a resident and were under the influence of marijuana at the facility. (Note: an internal investigation conducted by the facility identified the two staff as S1 and S4.)

- On 07/08/2025, the facility reported that there were three incidents involving staff physically or emotionally abusing residents, including a staff grabbing a resident by the shirt and hair sometime in 03/17/2025, a staff throwing cheese at a resident and laughing at the resident on 03/28/2025, and a staff encouraging a resident to eat raw onions that occurred at an unspecified date. (Note: an internal investigation conducted by the facility identified the staff who allegedly grabbed the resident by the shirt and hair as S5, the staff who allegedly threw cheese at the resident as S6, and the staff who allegedly encouraged the resident to eat raw onions as S7)

See LIC9099-C pages for more information. Page 1 of 3.