Facility Evaluation Report

At approximately 2:50, Licensing Program Analyst(LPA) Contreras arrived unannounced to conduct a Case Management Visit and was greeted by administrator (admin) Stephen Ngata. The purpose of the visit was to follow up on self reported incident that were submitted to Community Care Licensing (CCL).

CCL received multiple reported incident reports regarding the same client (C1). On 7/28/2025, CCL received incident report in which C1 went to the kitchen and used force to break into locked sharps drawer. C1 did not grab knife as staff intervened. LPA did a walk through of kitchen to ensure that sharps drawer is properly locked and secure, not allowing clients to have access. Sharps drawer has been moved to top of refrigerator cabinet with magnetic lock not accessible to clients.

Admin stated C1 has had medication change ,has a 2:1 staff ratio and has weekly meetings to ensure resident behaviors are being handled properly and also ensuring the safety of other clients. Admin stated receiving support from NBRC. Care plan to be updated.

During visit, LPA requested and collected the following forms during visit:

No deficiencies cited during todays visit .

Exit interview conducted, copy of report given.