Facility Evaluation Report

Licensing Program Analyst (LPA) Marisol Cuadra conducted an unannounced case management and met with mentor David Lear, Administrator Liz Jahren was not able to come to the facility but was available via phone and gave authorization for staff to sign the report. LPA explained to Administrator via phone the purpose of the case management visit was to follow up on incident reports regarding participants' recent falls during the last couple months and obtain additional information about preventive measures taken to prevent these ongoing incidents from keep happening.

Per incident report, on 04/01/26 around 2:45pm, participant (P1) was waiting for their bus when P1 reported to Senior Artist Coordinator, that they fell forward on the rug in the big room and landed on their hands and knees due to they were feeling dizzy because they had been sitting with their legs crossed. P1 was assessed and ice packs were applied by facility staff to P1, responsible parties were notified. Staff will continue to remind P1 not to sit with their legs crossed which causes them to get dizzy and to get up slowly and make sure they are not feeling dizzy before they start walking across the room. Based on LPA's records review of P1's physician report dated 10/01/24 and ISP dated 9/7/2025, P1 is ambulatory and is able to care for all personal needs including toileting needs.

Another incident happened on 4/21/26 at approximately 9:15am involving participant (P2), who was observed by staff crying in the hallway outside the bathroom and went to find P2 laying face down on the floor. Staff coached them up into a chair to assess for any injuries. P2 reported that they tripped on their way out of the bathroom but could not tell what they tripped on. Per P2, their knee and mild shoulder pain, and confirmed that they did not hit their head or chin, when the mentors found them their feet were both resting on top of their backpack. Continued on LIC809C...