Texas Health and Human Services Commission Child-Care Licensing Investigation Report Operation Information and Allegations: Operation #: Southwest Key Programs Inc - Casa Rio Grande 1514002 Investigation #: 2460349 IMPACT Case Id: IMPACT Call Id: 71081659 Intake(s): Intake Number Intake Date Received 2460349 06/27/2018 2462750 07/04/2018 Investigator's Name: RUBEN CANTU Extension Granted: No Allegation Type Standard/Law Violation Illegal Operations Suicide Attempt Child Death Serious Harm/Injury Critical Injury Child Arrest Illness Requiring Hospitalization Child Run Away Caregiver Drug Abuse Endangering Person Child Sexual Aggression Child on Child Physical Abuse Abuse/Neglect Physical Abuse Abuse/Neglect Sexual Abuse Abuse/Neglect Emotional Abuse Abuse/Neglect Physical Neglect Abuse/Neglect Medical Neglect Abuse/Neglect Neglectful Supervision Abuse/Neglect Exploitation # Children involved: 0 # Children involved: 0 Intake Priority: Priority 3 - minor violations of the law or minimum standards that involve low risk to children Investigation Priority: Priority 3 - minor violations of the law or minimum standards that involve low risk to children Date Priority Changed: Reason Priority Changed: Allegation Description: There are concerns with the supervision of children in care. There are also concerns with a staff member making threats to a resident in care. Investigation Persons: Reporter: See TAC 745.8483 Texas Health and Human Services Commission Child-Care Licensing Investigation Report Victim(s): Perpetrator(s): Name Perp Disposition Admin Review Release Hearing Investigation Documentation: Initiation Information: Initiation Date: 07/03/2018 Type of Initiation: Face to Face Information Obtained: I made face to face contact with Julia at Southwest Key Programs Inc-Casa Rio Grande on 07/03/2018. Julia said she cut her wrist because she is lonely and misses her family. Julia said she did it while she was showering. Julia said she is supervised well by staff at the operation. Julia said could not intervene because she was in the shower and they cannot supervise her while she is in there. Julia told me she is not 17 years of age. Julia told me she is 20 years of age. Julia said she told operation staff about her real age. Julia said they placed her on a one to one. Note: Please refer to Contact List for full interview. Observations Made During Inspection: Inspection(s): 3698314 3692263 3695530 I conducted an Investigation Inspection at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. A walk-through of the facility was conducted and no obvious fire, safety, or health hazards were observed. Background checks for staff interviewed on 07/03/2018 and all were cleared. Contact List: Type Date To:/With Phone Call 08/14/2018 Jose Izaguirre (Director) I made telephone contact with Jose Izaguirre to conduct the exit interview on 08/14/2018. I informed Mr. Izaguirre of the investigation findings and let him know there would be one deficiency cited related to the investigation. I then provided Mr. Izaguirre with the compliance date and informed him of the administrative review process. I told Mr. Izaguirre I would be sending him an investigation letter via Texas Health and Human Services Commission Child-Care Licensing Investigation Report email by the end of the day. Other 08/14/2018 Risk The investigations findings were discussed with RCCL Inspector Fabian De La Pena. Information provided on the intake and gathered throughout the investigation was discussed. I informed Inspector De La Pena the child involved in the incident was able to obtain a sewing needle during sewing class and cut her wrist while showering. I also informed Inspector De La Pena there were concerns with supervision as staff did not ensure to follow proper procedures when accounting for the sewing needles after class. I informed Inspector De La Pena collateral information confirmed staff did not follow proper procedures. I also let Inspector De La Pena know there was not enough evidence to cite the operation for a staff allegedly threatening a resident in care with filing a report if she did not get back in line. There will be one deficiency cited related to the investigation. We agreed medium risk at this time. Face to Face 08/14/2018 Ingrid (Minor in Care) I made face to face contact with Ingrid at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 08/14/2018. I introduced myself Ingrid and then explained the purpose of the visit and the role of Licensing. I observed Ingrid to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Ingrid to establish rapport, Ingrid agreed to be interviewed. Ingrid told me she is 17 years old. Ingrid said she has been here for 68 days. Ingrid said she is doing well and said they treat her good. Ingrid said they meet all of her basic needs. Ingrid said they are given three meals a day and three snacks per day as well. Ingrid said when they do not follow the rules they file a report or lose privileges like watching movies or go to Zumba class. Ingrid said she is not verbally or physically mistreated. Ingrid said she is not afraid of anyone here. Ingrid said she does not know any staff named Rosa but said she usually forgets staff names so she might know who Rosa is. Ingrid said she does not remember a minor named Julia. Ingrid said she not heard any staff threaten a minor with making a report while she is standing in line getting ready for breakfast or lunch. Ingrid said no staff has threatened her with making a report for any reason. Face to Face 08/14/2018 Francisca (Minor in Care) I made face to face contact with Francisca at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 08/14/2018. I introduced myself Francisca and then explained the purpose of the visit and the role of Licensing. I observed Francisca to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Francisca to establish rapport, Francisca agreed to be interviewed. Francisca told me she is 16 years of age. Francisca has been here for two months. Francisca said she is fine and mentioned everyone has treated her well. Francisca said she has all of her basic needs. Francisca said she is given three meals and three snacks. Francisca said if they do not follow the rules reports will be made. Francisca said their case may be delayed or they are placed on a one to one observation. Francisca said she has not been mistreated verbally or physically. Francisca said she does not know a staff named Rosa but said she did know Julia. Francisca said she does remember being in line with Julia for breakfast and lunch and said she does not remember if anyone said anything to Julia. Francisca said she has not heard any staff threaten to make a report against any minor in care. Francisca said no staff has threatened her with making a report against for Texas Health and Human Services Commission Child-Care Licensing Investigation Report any reason. Face to Face 08/14/2018 Jeraldy (Minor in Care) I made face to face contact with Jeraldy at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 08/14/2018. I introduced myself Jeraldy and then explained the purpose of the visit and the role of Licensing. I observed Jeraldy to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Jeraldy to establish rapport, Jeraldy agreed to be interviewed. Jeraldy told me she is 15 years old. Jeraldy said she has been here for the past three months. Jeraldy said she has been fine and mentioned they treat her well. Jeraldy said they meet her basic needs. Jeraldy said she is provided three meals a day as well as snacks. Jeraldy said when they misbehave and not follow the rules they file a report. Jeraldy said the report may affect their case. Jeraldy said they also lose privileges like not being to play outside or participate in special events. Jeraldy said she knew Julia but does not remember any staff threatening her. Jeraldy said she might know who staff Rosa is but not by name. Jeraldy said she does not really memorize the names of the staff members. Jeraldy said staff are not mean or threaten them when they are lined up for breakfast or lunch. Jeraldy said none of the staff have threatened her in anyway. Face to Face 08/14/2018 Cesar Gerardo Anguiano (Vocational Coordinator) I made face to face contact with Cesar Gerardo Anguiano at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 08/14/2018. I introduced myself to Mr. Anguiano and then explained the purpose of the visit. Mr. Anguiano stated he has been the Vocational Coordinator since the incident with Julia. Mr. Anguiano stated he is responsible for ensuring all sewing materials and equipment is accounted for. Mr. Anguiano stated prior to the incident with Julia they had a procedure in place to ensure needles were returned. Mr. Anguiano stated each minor would get a needle and the staff would write down the name and when the needle was returned the staff would scratch the name to indicate the needle was returned. Mr. Anguiano stated after the incident with Julia he has removed the all of the individual needles. Mr. Anguiano stated the only needles used by minors are the ones in the sewing machine. Mr. Anguiano stated once the needle in the sewing machine is no good they have to provide him with the bad needle before he can replace it with a new one. Mr. Anguiano stated if the bad needle is not returned to him he will not replace it with a new one and they will need to look for the bad one. Mr. Anguiano stated at that time the sewing class would stop and they would review cameras to see what happened and find the needle. Mr. Anguiano stated this is done to prevent a similar incident like Julia’s to occur. Mr. Anguiano stated it was going to be difficult to find out what staff member was in charge of the sewing class around the time Julia took the needle. Mr. Anguiano stated they rotate sewing class from to room every two weeks. Mr. Anguiano stated classes are offered for seven hours each of the two weeks. Face to Face 08/14/2018 Omar Ramirez (Shift Leader) I made face to face contact with Omar Ramirez at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 08/14/2018. I introduced myself to Mr. Ramirez and then explained the purpose of the visit. Mr. Ramirez stated prior to the incident staff needed to make sure the needles were returned to them by the end of the class. Mr. Ramirez stated they have the same procedure for scissors or any sharp objects. Texas Health and Human Services Commission Child-Care Licensing Investigation Report Mr. Ramirez stated they have had new staff and possibly one them did not follow procedures and the minor somehow got a hold of a needle. Mr. Ramirez stated they are being more careful and indicated new procedures have been implemented to ensure the safety of the minors. Mr. Ramirez stated it was going to be difficult tracking down who the staff member in charge of sowing class was the day Julia took the needle. Mr. Ramirez stated they alternate sewing class from room to room every two weeks. Mr. Ramirez stated as far as staff member Rosa Cobarrubias he does not have any concerns. Mr. Ramirez stated minors have not come up to him complaining Ms. Cobarrubias has said anything inappropriate or threatening. Mr. Ramirez stated Ms. Cobarrubias has not been reprimanded for such behavior. Mr. Ramirez stated she has been written for tardiness and disagreements with other staff but nothing against minors in care. Other 08/09/2018 Email On 08/09/2018 Director Jose Izaguirre sent me emails with attachments indicating Julia was not a minor. On the attachments are letters stating Julia real name is Santos Cael Che and her real date of birth is 07/17/1997. This was verified through the Guatemalan consulate through legal documents like birth certificate and photo identification. Note: Copies of the attachments may be found in the external file. Phone Call 08/06/2018 Rosa Cobarrubias (Staff) I made telephone contact with Rosa Cobarrubias on 08/06/2018. I identified myself and then explained the purpose of the phone call. I addressed the allegations with Ms. Cobarrubias as well as informing her of the investigation process. Allegations were addressed with Ms. Cobarrubias and she stated she is currently suspended because of the incident. Ms. Cobarrubias stated she has been off work for the past three weeks. Ms. Cobarrubias stated she was not aware of any issues or concerns Julia had until she was suspended. Ms. Cobarrubias stated their well-being and safety is very important to her and she would never threaten a minor in care. Ms. Cobarrubias denied threatening Julia with making a report for any reason. Ms. Cobarrubias stated she never threatened her at any moment. Ms. Cobarrubias stated she does not understands why this is happening to her. Ms. Cobarrubias stated she does remember Julia asking her if she would get paid for making reports. Ms. Cobarrubias stated she told Julia that was part of her job but not all of what her job consists of. Ms. Cobarrubias denied threatening Julia with making a report. Ms. Cobarrubias stated she rarely documents any reports and stated reports are for when they do not follow the rules. Ms. Cobarrubias stated she would not just make report against a minor for no reason. Ms. Cobarrubias stated making reports on minors will delay their case and that is something she would not do to them. Ms. Cobarrubias stated hopefully this clears up so she can return to work. Face to Face 07/26/2018 Jose Izaguirre (Director) I made face to face contact with Jose Izaguirre at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/26/2018. I greeted Mr. Izaguirre and explained the purpose of my visit. Mr. Izaguirre stated the staff member who allegedly threatened Julia is currently suspended. Mr. Izaguirre also stated once they confirm Julia is over the age of 17 she will immediately be discharged. Mr. Izaguirre also informed me Clinician Leticia Cavazos was no longer in his program. Texas Health and Human Services Commission Child-Care Licensing Investigation Report Face to Face 07/26/2018 Julia (Child in Care) I made face to face contact with Julia America at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/26/2018. I introduced myself Julia and then explained the purpose of the visit and the role of Licensing. I observed Julia to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Julia to establish rapport, Julia agreed to be interviewed. Julia said a staff member named Rosa told her she would file a report if she did not listen. Julia said the staff member did not like the fact she went to another line. Julia said they were getting ready for breakfast when this happened. Julia said they lined up in the normal 8 minors per line. Julia said she felt like it was too much for Rosa to have two minors in close observation so she decided to go to another line with less than eight children. Julia said Rosa did not like this and for that reason told her she would file a report if she did not listen. Julia said she ended up staying in Rosas group. Julia said she felt bad afterwards. Julia said after breakfast Rosa the staff member noticed she was sad and went up to her and told her she was joking. Julia said this has been the only time it has happened. Julia said no one had ever talked to her like that. Julia said she told her clinician what happened. Julia said they made a report on Rosa and said she has not seen her since the incident. Phone Call 07/25/2018 Leticia Cavazos (Clinician) I attempted telephone contact with Leticia Cavazos on 07/6/2018. No one answered the phone. Phone Call 07/23/2018 Leticia Cavazos (Staff) I attempted telephone contact with Leticia Cavazos on 07/23/2018. No one answered the phone. Face to Face 07/03/2018 Leticia Cavazos (Clinician) I made face to face contact with Leticia Cavazos at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself and explained the purpose of the interview to Ms. Cavazos. I then addressed the allegations with Ms. Cavazos. Ms. Cavazos stated she is Julia's clinician. Ms. Cavazos stated she has weekly sessions with Julia where they discuss how she is doing and her feelings. Ms. Cavazos stated Julia is not diagnosed with anything and is currently not under any medication. Ms. Cavazos stated during the sessions she focuses on coping skills to manage and help her with her feelings. Ms. Cavazos stated Julia is a little frustrated and also feeling a little sadness which is normal especially being away from her family. Ms. Cavazos stated she did not understand why Julia would try to self harm if she is always so happy and smiling. Ms. Cavazos stated Julia has no history of self-harm or suicidal ideation. Ms. Cavazos stated Julia might have done this because she felt shame, regret, and a little lonely. Ms. Cavazos stated Julia told she did not know what happened or why she did it. Ms. Cavazos stated Julia did not know what else to do. Ms. Cavazos stated Julia told her she was not planning on killing herself. Ms. Cavazos stated Julia told her she had never thought about it or attempted to self harm before. Ms. Cavazos stated Julia did mention to her she feels overwhelmed and wants to go home. Ms. Cavazos stated the supervision to minors in care is appropriate. Ms. Cavazos stated when minors are in their room staff will do a head count every 15 minutes. Ms. Cavazos stated minors are given five minutes to use the restroom and five minutes to shower. If they take longer than that staff will then go in the room and knock on the door and ask if they are okay. Texas Health and Human Services Commission Child-Care Licensing Investigation Report Face to Face 07/03/2018 Tania Gissele Fortin Duarte (Minor in Care) I made face to face contact with Tania Gissele Fortin Duarte at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself Tania and then explained the purpose of the visit and the role of Licensing. I observed Tania to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Tania to establish rapport, Tania agreed to be interviewed. Tania said she is 17 years of age. Tania said she has been here a month today. Tania said she has been doing well. Tania said she has no concerns and said everyone has treated her well. Tania said everyone is really nice. Tania said she has all of her basic needs met. Tania said she gets three meals a day and three snacks. Tania said if they don’t follow the rules a report is filed or you are placed on observation. Tania said they will also remove privileges like not letting them go outside. Tania said she is not mistreated and said she is not afraid of anyone here. Tania said they supervise them all the time. Tania said when they are in their room the caregiver is outside of the room supervising them. Tania said they do not go into the room unless there is an emergency or if someone takes too long in the restroom. Tania said they are given five minutes to go to the bathroom and five minutes to shower. Tania said they supervise them appropriately. Tania said she is not aware of anything happening with her roommates recently. Face to Face 07/03/2018 Ingrid (Minor in Care) I made face to face contact with Ingrid at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself Ingrid and then explained the purpose of the visit and the role of Licensing. I observed Ingrid to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Ingrid to establish rapport, Ingrid agreed to be interviewed. Ingrid said she is 16 years of age. Ingrid said she said she has been here 31 days. Ingrid said it has been going well. Ingrid said they have treated her well and mentioned she feels fine. Ingrid said she all of her basic needs met. Ingrid said they are given three meals a day as well as three snacks. Ingrid said she always behaves and mentioned she does not know what happens when someone does not follow the rules. Ingrid said she tries to stay out of trouble. Ingrid said she is not mistreated and said she is not afraid of anyone here. Ingrid said they are supervised well. Ingrid said when they are in their rooms the caregiver is standing outside the room next to the door. Ingrid said she is content with the supervision. Ingrid said she is not aware if anything has happened recently with any of her roommates. Face to Face 07/03/2018 Rosalinda (Minor in Care) I made face to face contact with Rosalinda at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself to Roslinda and then explained the purpose of the visit and the role of Licensing. I observed Rosalinda to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Rosalinda to establish rapport, Rosalinda agreed to be interviewed. Rosalinda said she is 16 years of age. Rosalinda said has been here for 70 days. Rosalinda said it has been going well. Rosalinda told me she has been calm and tries not to think about being here. Rosalinda said they treat her really well. Rosalinda said staff are really nice and said they listen to them. Rosalinda said she has all she needs and mentioned they provide her with all of her basic needs. Rosalinda said she Texas Health and Human Services Commission Child-Care Licensing Investigation Report is fed three meals a day along with snacks. Rosalinda said she follows the rules but mentioned they will take down a report when rules are not followed. Rosalinda said they will also remove privileges like play games, go outside, listen to music, or watch videos. Rosalinda said she is not mistreated and said she is not afraid of anyone here. Rosalinda said when they are in their room there is a staff outside of the room. Rosalinda said they do not enter the room unless they really have to like an emergency or they need or clean or replace items. Rosalinda said they are supervised well. Rosalinda said she has discussed with her youth care worker that there is a lot of security here. Rosalinda said she likes the supervision because if there was no supervision things would be out of order. Rosalinda said it helps them build respect to one another. Regarding the allegations Rosalinda said she saw the marks on Julia’s wrist. Rosalinda said that same day a staff member noticed them as well. Rosalinda said Julia said she was placed on a one to one. Rosalinda asked Julia why she did it but she did not give her an explanation. Rosalinda said Julia told staff she did it because she felt lonely and missed her mother. Rosalinda said she would report it to someone if she had firsthand knowledge of something like this. Rosalinda does not want anyone to get hurt. Face to Face 07/03/2018 Jose Barroso (Case Manager) I made face to face contact with Jose Barrios at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself to Mr. Barrios and then explained the purpose of my visit. I then addressed the allegations with Mr. Barrios. Mr. Barroso stated Julia has been here since October. Mr. Barroso stated Julia has been sad because she misses her child who is five or six years of age. Mr. Barroso stated it seems Julia is done and wants to go back to her home country. Mr. Barroso stated he sees Julia on Tuesdays to discuss her case. Mr. Barroso stated during one Julia’s weekly phone call that she spoke to her mother and she seemed nervous. Mr. Barroso stated after the phone call Julia told him she needed to tell him something and she came clean about her age. Mr. Barroso stated Julia’s mother advised her to come clean regarding her age. Mr. Barroso stated ever since she told him the truth she has been happy. Mr. Barroso stated when she arrived at the operation she did not seem like she was a minor. Mr. Barroso stated he always had his suspicion. Mr. Barroso stated Julia called her mother again and asked her mother to send her birth certificate and marriage license. Mr. Barroso stated they have received the documents and once they are authenticated she will be removed from program. Mr. Barroso stated it takes a while to authenticate. Mr. Barroso stated Julia really wants to leave and go back home because she wants to see her baby. Mr. Barroso stated they are making sure she is an adult and not just go based on what Julia is saying. Mr. Barroso stated they need to make sure they are not sending a minor to immigration. Mr. Barroso stated they need two verifications to prove she is an adult a birth certificate and her ID card along with her declaration. Face to Face 07/03/2018 Julia (Youth in Care) I made face to face contact with Julia at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself and explained the purpose of the visit and the role of Licensing. I observed Julia to be appropriately dressed and also presented proper hygiene. After engaging in further discussion with Julia to establish rapport, Julia agreed to be interviewed. She Julia told me she is 17 years of age. Julia said she has been here for nine months this 11th of July. Texas Health and Human Services Commission Child-Care Licensing Investigation Report Julia said they have treated her well and mentioned they are nice and courteous to her. Julia said they have provided her with all of her basic needs. Julia said she gets three meals a day as well as three snacks. Julia said when they do not follow the rules they will placed on observation one to one or removal of privileges like going outside or play with games or watch movies. Julia said she is not afraid of anyone at the operation. Regarding the allegations Julia said approximately two weeks ago she felt alone and so when she was in bathroom showering she started cutting herself with a needle. Julia said she did not tell anybody about doing this. Julia said she thought about it that same day and was not something she had been planning. Julia said she took the needle from her sowing class. Julia said she hid the needle and took it to her room that day. Julia said she had never done something like this before. Julia said she regretted doing it because she thought about her family and said she wants go back to them. Julia said she will not do something like this again. Julia said she did not tell anybody about what she did. Julia said she always wears a sweater and one day she forgot her sweater and a staff member noticed the marks on her wrist. Julia said as a result of what she did she was placed on one on one supervision. Julia said they spoke to her about what she did. Julia said everyone is nice to her here but what she needs is her family. Julia said she wants to go back to her country to be with her family. Julia said she is not diagnosed with anything and is not taking any medication. Julia said they are supervised well. Julia said she did this because it was in her head and asked how would staff know she was going to do self-harm. Julia said staff was outside the room supervising in the hallway and had no idea of what she was doing. Julia did not like being dishonest so she told her case manager she was not a minor. Julia said she self-harmed the same day she told her case manager she was lying about her age and not a minor. Julia said she came clean after to speaking to her mother on the phone and her mother advising her to be honest. Julia said her real date of birth is XX/17/XXX. Face to Face 07/03/2018 Irma Perez (Interim Assistant Program Director) I made face to face contact with Irma Perez at Southwest Key Programs Inc - Casa Rio Grande #1514002 on 07/03/2018. I introduced myself to Ms. Perez and then informed of the reason for my visit. Ms. Perez stated she had some information regarding the incident and would also be providing me with anything I needed. Ms. Perez stated Julia did this in her room in the bathroom. Ms. Perez stated Julia scratched herself with a needle on her wrist. Ms. Perez stated this is the first incident of this nature with Julia. Mr. Perez stated there have been no previous incidents with Julia. Ms. Perez stated Julia said she did this because she had disclosed she was an adult to her case manager. Ms. Perez stated Julias mother had asked to be honest about her age. Ms. Perez stated Julia mentioned Julia said disclosing she was an adult really made her sad and that is why she did it. Ms. Perez stated Julia said she had no intention of killing herself. Ms. Perez stated Julia is not diagnosed with anything. Face to Face 07/03/2018 Jose Yzaguirre (Administrator) I made face to face contact with Jose at Southwest Key Programs Inc-Casa Rio Grande on 07/03/2018. I introduced myself and explained the purpose of my visit. I then addressed the allegations and informed him of the investigation process. Texas Health and Human Services Commission Child-Care Licensing Investigation Report Investigation Findings: Disposition (if A/N): Explanation of Disposition: Based on the preponderance of evidence one deficiency related to the investigation will be cited. An intake was received stating a resident self harmed by cutting herself on the wrist with a sewing needle. A subsequent intake was received indicating the same resident was verbally threatened by a staff member. After conducting interviews with staff, shift leader, and residents in care it was determined the operation did follow through with their procedure of accounting for all of the needles once the residents were done with sewing class. Julia a resident was able to keep a sewing needle after class and took it to her room. While Julia was showering she cut herself on her wrist leaving lacerations. Staff was not able to intervene as they are not allowed in the bathrooms with the residents in care. Julia did not tell anyone about what she did before or after. A staff member noticed the marks on her wrists and took proper action by alerting a shift leader. Julia was placed on one to one observation and no further incidents were reported. Julia said she did not intent to commit suicide and only did it because she was lonely and missed her family and did not know what else to do. On that same day Julia admitted to her case manager she was not a minor but an adult. Julia came clean after speaking to her mother who encouraged her to be honest about her age. It was later verified through the Guatemalan consulate that indeed Julia's real name was Santos and in fact she was an adult. Julia has been discharged from the operation as she is not a minor. Regarding the staff member threatening Julia it was not determined if in fact the staff did so. Staff Rosa Cobarrubias was suspended due to the allegations made against her and when I spoke to her she denied threatening Julia in any way. Julia said Ms. Cobarrubias threatened her with making a report if she did not return to line. Julia said this made her feel bad. I spoke to residents in care who knew Julia and would at times be lined up with her on their way to breakfast or lunch and all said they never heard anyone threatened Julia. None of the minors interviewed throughout the investigation said they were ever threatened in any way by a staff member. MS. Cobarrubias also does not have any reprimands related to inappropriate comments or threats to residents in care. The Director and a shift leader I spoke to had no concerns with Ms. Cobarrubias. The case will be closed after a correction plan is submitted. The current risk is medium. Recommended Action: No action Action Dates: Notification to Provider: 08/14/2018 Investigation Complete: 08/14/2018 Investigation Closed: 09/13/2018