Facility Evaluation Report

On 08/28/2025 at approximately 1:35 PM Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management visit regarding two self-reported incidents that occurred approximately on 08/19/2025 and 08/26/2025 involving client (C1). LPA met with Administrator Dyemond Mitchell. On both occasions C1 had hidden items to commit acts of self-harm. C1's room was immediately inspected for potential items and a plan for regular and random room inspections was put into place, with C1's consent.

LPA reviewed the records of C1 and found that staff were aware of the behaviors and had the required staff in place, including a BCBA (Board Certified Behaviorist) and had conducted training for all staff. The Behavior Plan shows that C1's behaviors had been tracked had not shown any indications of escalation. After the incident on 08/26/2025, additional training was held for staff. C1 has a one to one within line of sight at all times. C1 may request privacy at times but sight checks will be done every 15 minutes. C1's behavior team met on 08/22/25 and updated behavior plan. Team will continue to support as needed.

No deficiencies were found. No citations issued.