Facility Evaluation Report

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit today for the purpose of investigating a self-reported incident report and SOC 341. Upon arrival, LPA met with Program Director, Laura Wood, and at this time the reason for the visit was explained. Entrance interview.

On 11/14/2025, the Department received an incident report stating that facility staff were informed of an incident that occurred on 11/11/2025 involving Staff #1 (S1) being unprofessional around clients. Clients reportedly felt uncomfortable around S1 because S1 frequently appeared upset. It was reported that while waiting for other staff and clients to use the restroom, S1 stated, “What the f*** are they doing?” in the presence of clients. As the day progressed, Client #1 (C1) attempted to sit next to a specific staff member and talk to other clients, but S1 did not allow C1 to sit next to the other staff member and instructed C1 to stop bothering their peers. The following day, S1 asked C1 to sit in the back of the van because C1 was “bothering them.”

During today’s visit, the LPA conducted interviews with two staff members and one client between 9:50 a.m. and 1:30 p.m., conducted a file review at approximately 10:45 a.m., and obtained copies of pertinent documents.