Incident investigation·November 5, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with DSP staff, Junald Nate and Olive Jackson. Dennis Abadilla, Administrator Designee, arrived shortly and LPA stated the reason for the inspection. LPA and the Administrator discussed an incident when (C1) was in the bathroom on November 1, 2025 (7:30 pm) and fell to the floor, face down. (S1) went to get another staff to assist when she observed blood on the right eye socket area and called another staff to assist. (C1) got up on their own and staff observed a cut on the right and left orbital. The administrators were contacted and requested staff take (C1) to to the hospital for further medical evaluation. The CT Scan showed no fractures on the head or spine; however, there was a fracture on the maxillary bone. (C1) received sutures, antibiotics and returned the same day. A follow up appointment is scheduled on November 10, 2025 to have the sutures removed and determine if a referral to the oral surgeon is needed. The administrator stated (C1) returned to day program on Monday, November 3, and has been attending all week. LPA observed (C1) return from the day program at the start of the inspection and to be ambulating fine. LPA observed the bruising on (C1's) right eye area and the administrator stated (C1) seems to be back to baseline- their appetite is okay. The administrator stated (C1) will often pretend to be fainting to get attention from staff and has also done this while being transported to day program. (C1) is now required to be in a wheelchair during transport. LPA reviewed (C1's) Individual Health Care/Nursing Plans which note "caregivers should be aware that (C1) may have sudden movements and pseudo seizures behaviors and to ensure safety from injury during these events". The administrators will review the Nursing Care Plan with all staff to reinforce what steps can be taken to minimize any injuries. The facility took immediate action in getting (C1) medically evaluated. (C1) was last injured in December 2024. There are no deficiencies issued. Exit interview. Copy of report provided.