Incident investigation·August 25, 2025

On 08/25/2025, Licensing Program Analyst (LPA), Robert Maciel made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR) and met with facility representative Susan Jenkins (S1). The UIR was notified to Community Care Licensing on 08/20/2025. The incident was regarding a child (C1) who had jumped down a retaining wall in the far yard and cut his shin on an exposed screw. As written in the UIR, the far yard was closed and on Thursday 8/21/25, the broken screw was pulled and repairs were made. During today's inspection, LPA toured the far yard which revealed that the screw had been removed and that there were no other hazards present. Staff Melanie Campbell (S2) stated that the screw was a remnant from padding that was installed on the wooden retaining wall that had deteriorated, leaving only the screw and that the facility was planning on removing the padding and remaining screws. The following title 22 deficiencies were observed during today's visit (see LIC809D). Appeal rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with Facility Representative, Susan Jenkins.