Facility Evaluation Report

05/06/2025 12:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Anna Castillo-Virgen. Today’s visit is regarding an incident that occurred on 03/18/2025 and was reported to licensing on 03/20/2025.

It was reported that on 03/18/2025 Client 1 (C1) went into their room to have quiet time. C1 started making comments about doing something bad but wasn't going to tell staff what they did because they were worried that staff would be mad and yell at them. Staff asked multiple times what C1 was talking about, but C1 refused to say. After about 10 minutes C1 told staff that they inserted a small item into a post-surgery wound on their left leg. C1 refused to show staff what they had done to themselves. Five minutes later C1 showed staff their wound and staff discovered that C1 had inserted a thumb tack into the wound. Staff safely pulled the thumb tack out, cleaned the wound and covered it with a fresh band aid. C1’s family was notified, staff took C1 to the clinic where a physician inspected the wound, determined it was not infected, and prescribed an antibiotic ointment.