Facility Evaluation Report

At approximately 2:10 PM Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident visit. LPA was greeted by Charisma Nieves Mari, Administrator/Licensee and signed the Visitor's Log. LPA informed Administrator/Licensee the purpose of today's visit was to investigate a suicide threat from C1 as reported via an incident report dated 4/29/2024 at 11:00 PM and received by CCLD on 04/30/2024. LPA requested copies of C1's most recent medication list, individual service plan created by her behaviorist, and notes from her most recent psychiatry visit. Per Licensee/Administrator, C1 has been adjusting her medications with her Psychiatrist due to feeling tired and unmotivated, but is now back on medication to help with suicidal thoughts.

Incident Report: CCL received an incident report noted above which stated that on 4/29/2024 at approximately 11:00 PM, C1 reported to staff feeling anxious again. She kept leaving her room and expressing that she could not fall asleep and and didn't feel well. A staff member offered her some tea to help alleviate her anxiousness. However, C1 reported continued feelings of restlessness and anxiety. According to the IR and interview today with Licensee, C1 stated that she began to feel she was going to be violent and wanted to hurt herself. C1 further expressed wanting to go to the ER and C1 called 911. C1 was taken to Kaiser Vacaville ER, was kept over night and released at 6:00 AM the following morning.

Facility made all appropriate notifications per regulation.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.