Incident investigation·April 23, 2024

Licensing Program Analyst (LPA) Mary FLores conducted an unannounced case management visit regarding incident report submitted to the facility on LPA met with Lori Lackey and Rocio Gonzalez and explained the reason for the visit. On 4/16/24 the department received incident report which reports on 4/13/24 Resident #1(R1) jumped over the fence and left the facility. Staff went out to search for R1 and police was contacted. R1 was found by someone who lives in the neighborhood on Oak Knoll St., the individual called 911 after witnessing R1 fall down. R1 was then transported to the hospital. On 4/19/24 LPA contacted Lori Lackey and requested physician's report, needs and care plan, hospital discharge documents for R1. During this visit LPA reviewed the documents and tour the facility. Per the incident report R1 jumped over the fence in the courtyard that faces El Molino St. Fence at 1:59pm. The fence is over 6ft in high. Staff noted R1 missing at 2:10pm. Per physician's report dated: 9/8/23 R1 cannot leave the facility unattended due to cognitive skills. Per Individual Service Plan dated 12/5/23 R1 has a history of wandering and leaving unassisted. Needs and Service Plan dated 4/22/24 notes R1's wandering behavior and staff will provide monitoring due to wandering. Medication sheet shows medication was adjusted on 4/23/24. Admission agreement shows R1 was admitted on 4/9/24. Per Assistant administrator R1 is still assimilating to the facility, a psychological evaluation was conducted on 4/22/24 and adjustment in medication has been done by the physician. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey and a copy of this report, LIC 809D, and appeal rights were provided.