Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident Visit and met with Diana Mendez, Program Manager. The purpose of this Case Management Visit is to conduct a follow up on incident report submitted to Community Care Licensing (CCL) on 11/17/25.

Per incident report, On 11/12/25 at approximate 2:20pm participant (P1) was exiting the building with their wheelchair when they caught their left leg on the door, P1 immediately began to scream, staff (S1) and LVN asked P1 if they were ok, P1 stated that their big toe was hurting, LVN immediately assessed P1's left leg and did not notice any bruising or swelling, they notified P1's responsible parties as P1 was getting ready to go home for the day. On 11/14/25, P1's responsible party notified day program supervisor that P1 had a fracture due to the incident.

During today's visit, LPA reviewed records of P1's physician report dated 10/1/25 indicating that P1 is not able to ambulate without assistance, which it is supported by day program's ambulatory status completed by P1's physician dated 10/1/25 revealing that P1 is not capable of exiting a building safely in case of emergency and determining that P1 would require full assistance to exit a building safely.