Facility Evaluation Report

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

The purpose of the visit was to follow up on incidents reported to the department by the facility as well as a report of a semi-annual review conducted by the Department of Developmental Services (DDS) that was submitted to the department.

On 11/27/2025, the facility submitted an Unusual Injury/Incident Report (IR) about an incident that occurred on 11/26/2025 at approximately 5:00 PM. The incident involved three staff who transported resident R1 to a nearby Walmart via van. When the van arrived at Walmart, R1 began hitting his/her head. Staff decided to send one staff, S1, into the Walmart to buy items for R1. The other two staff, S2 and S3, remained with R1 in the van. S2, the driver of the van, drove the van to a nearby park to help R1 self-sooth. After arriving at the park, R1 ran away from S2 and S3. S3 attempted to pursue R1 but lost visual contact with R1. The staff called 911 and 911 dispatch informed the staff that R1 was at the Walmart. The staff picked up R1 in the van and returned R1 to the facility by approximately 6:50 PM.

During visit on 1/15/2026, LPA Marrufo interviewed staff S1 and S2. S1 stated R1 had gone missing for about an hour. S2 stated R1 had gone missing for about 10 minutes. Both S1 and S2 stated that staff had lost visual contact with R1 after R1 ran away at the park.

See LIC809-C page for more information. Page 1 of 2.