Follow-up on corrections·January 2, 2025

Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit on 01/02/24, at 11:28 AM, LPA Lee met with administrator Edna Clegg and explained the purpose of the visit. The census is 6. The purpose of today's visit is to follow up on a LIC 624 incident report that the department received on 12/22/24. The incident report is regarding an absent without leave (AWOL) event that occurred on 12/15/24. It was learned that resident 1 (R1) left the facility unassisted at 9:30 AM to attend church and did not return to the facility the entire day. It was also learned that administrator Edna observed R1 signing himself out using the facility sign in and out sheet. Facility staff Maxwell contacted local emergency and law enforcement regarding a missing person. In an interview with facility staff Maxwell, the facility overlooked and didn’t recognize that R1 was unable to leave the premises without assistance. Both Administrator Edna and staff member Maxwell stated that they were unaware of how (R1) ended up at the hospital. In an interview with R1’s Service Coordinator, it was revealed that R1 walked to Walmart after church, where R1 experienced a fall and then a pedestrian helped R1 to Walmart, but upon entering the store, R1 had another fell. Walmart then called an ambulance, and R1 was transported to Methodist Hospital. Furthermore, R1's LIC 602 Physician’s Report, dated 08/12/24, indicates that R1 has mild cognitive impairment and is not capable of leaving the facility unassisted. Based on today’s case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed on 01/01/25 due to lack of care and supervision and an immediate health and risk to R1. An exit interview was conducted with administrator Edna. A copy of this LIC 809, LIC 809-D, LIC 421-IM and appeal rights was provided to the facility at the end of the visit.