Facility Evaluation Report

Licensing Program Analyst, (LPA) Valeria Conway, conducted an unannounced Case Management – Incident visit to the facility to follow up on a self-reported incident received. At 10:15 A.M., the LPA met with Administrator/TeamLead, McKain Nielsen and explained the reason for the visit. Entrance interview

On 11/2/2025 Community Care Licensing (CCL) received a self-reported incident from the facility indicating that Client #1 (C1) and Client #2 (C2) were involved in a physical altercation. According to the incident report, at approximately 11:44 A.M, C1 was observed striking C2 on the head during the altercation. Facility staff contacted 911 at 11:52 A.M. At approximately 12:15 P.M. law enforcement and emergency medical personnel responded to the facility. As a result, C1 was taken into custody by responding law enforcement officers, and C2 was was transported to the emergency room for medical evaluation and treatment.

During today's visit, the LPA interviewed facility staff regarding the event, conducted a brief physical plant tour, reviewed relevant client records, and obtained copies of documentation related to the incident. LPA discussed with the administrator the importance of ensuring client safety and staff response procedures during behavioral incidents or physical alterations.

At this time, LPA determined that further investigation is needed. A supplemental report will be issued, if warranted.

Exit interview conducted and a copy of report provided was provided.