Facility Evaluation Report

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Management – Incident visit for the purpose of investigating a self-reported incident report. Upon arrival, LPA met with Program Manager Andy Garcia explained the reason for the visit.

On 10/20/2025, While being transported back to day program form an outing Client #1 (C1)'s wheelchair tilted to the right, when the van was turning, the turn cause C1 and their wheelchair to fall towards the right of the van. Staff state that C1 made a scream/yell which caused them to

look back and they saw C1 catch themselves with their right hand/arm. Staff #1 (S1) pulled over to make sure C1 was okay when S1, and Staff #2 (S2) got to C1 and their wheelchair was observed laying on its' right side. S1 and S2 lifted C1 with their wheel chair to its upright sitting position and checked C1 for injuries. Staff observed a light scratch on C1's right elbow. No other injuries were reported.

Interviews conducted and records review revealed staff failed to ensure C1 was secure in the vehicle resulting in C1's wheelchair to become unbalanced and fall in the vehicle. An internal investigation was conducted between 10/22/2025 - 10/27/2025, and confirmed there was a preponderance of evidence that staff failed to ensure C1's safety in the van.

At approx 11:45 a.m. LPA conducted physical plant, interviewed staff, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D). Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted and copy of report issued.