Incident investigation·January 18, 2024

Licensing Program Analyst (LPA) Jamie Ivey Canady visited the facility unannounced and met with Administrator Irene Charnell and explained the reason for today's visit. According to Incident Report received by the Department from the facility on 1/15/2024, R1 is a member of facility Day Club. R1 was reported AWOL from the facility day club program at approximately 4:45 pm on 1/10/2024. According to facility document review, R1 had last been seen on the facility grounds by facility staff at 4:30pm. R1 was located on the same road as the facility, but outside the grounds next to a busy street at approximately 4:50pm by facility staff. According to facility incident report R1 was missing from facility grounds for less than 10 minutes. Based on facility resident file review, on page 2 of R1 Preplacement Appraisal Form LIC603, under services needed "Needs special observation/night supervision (due to confusion, forgetfulness, wandering), Yes is checked with a handwritten note "Yes to all. Constant Wandering". According to facility file document review, and facility invoice, facility had construction and repairs performed on the facility on 1/10/2024. Based on incident report, facility gate had been left slightly ajar by construction staff. It was learned that R1 accessed the outside of the facility grounds via the open section in the gate that had been left open by construction staff. However, based on Title 22 regulations, licensee responsibility for health and safety of R1 based on facility service agreement was not fulfilled. Therefore, based on Title 22 regulations, deficiencies cited. Exit interview held and copy of report given to Administrator Irene Charnell.