Incident investigation·December 10, 2021

On 12/10/2021 at 12:58PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 11/26/2021. LPA met with staff, Anna Horvath. Administrators, Telesha Clarke arrived 10-20 minutes later. Incident report dated 11/25/2021 revealed that police called facility at 4:45AM to inform staff that R1 was found outside of the facility. At 5:08AM, EMT arrived to take R1 to the local hospital. R1 returned to the facility at 10:15AM. Interview with staff revealed that R1 can turn off the door alarms and left the facility in the morning of 11/24/2021. S3 stated that R1 have not left the facility at night before and this was the first time. R1 has left the facility during the daytime, but staff observe R1 and able to redirect R1 if needed. R1 is moving out on 12/15/2021. During record review, LPA observed that physician's report dated 8/31/2021 stated that R1 cannot leave the facility unassisted. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.