Facility Evaluation Report

04/24/2025 02:30 PM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Anna Castillo-Virgen and explained the purpose of the visit. On 04/10/2025 LPA visited the facility to start the investigation, the purpose of today’s visit is to deliver the results of the investigation regarding an incident report that was received by licensing on 04/02/2025.

It was reported that on 3/15/2025 at approximately 12:00 PM Staff 1 (S1) was working with Client 1 (C1) in the dining room at the dining table. C1 was very antsy and would frequently get up and down out of the chair to walk and pace. S1 would redirect C1 back to their chair to prevent a fall and work closely with C1 utilizing a gait belt for support. Staff 2 (S2) claims they heard S1 say to C1 "you're so annoying," and telling C1 to "Shut the F up.” S2 claims they heard S1 say this to C1 four times.

During the investigation it was learned that there were three staff who were on duty at the time of the incident. LPA conducted interviews with all staff who were present on the date and time of the incident as well as staff who were not present. LPA reviewed staff schedule for the date and time of the incident. There were multiple inconsistencies during the interviews.

The preponderance of evidence standard has not been met. No deficiencies were cited as a result of the investigation.

Exit interview conducted and a copy of the report was provided to with administrator Tamra Leak.