Incident investigation·March 27, 2025

On 03/27/25 Licensing program analyst (LPA) Villegas conducted an unannounced case management visit in regards to incident report dated 03/23/25 that was sent to the department on 03/25/25. LPA met with Executive Director Ezperanza Naakgebored as the purpose of the visit was explained. During the visit LPA obtain the following documents for resident #1 (R1); emergency ID form with date 7/7/22, physicians report dated 1/9/25, physicians orders dated 03/01/25, resident assessment form dated 3/26/26, preplacement appraisal dated 7/6/22, and psychiatric evaluations dated 12/5/24, 1/9/25, crisis plan dated 3/17/25, and summary report from ROADS community clinic dated 3/3/25. On 03/27/25 LPA conducted a tour of the facility, and took pictures of the window in the bedroom where the incident occurred. Due to insufficient information available at this time, the visit requires a need(s) further investigation.