Incident investigation·November 28, 2023

Licensing Program Manager (LPM), Laura Munoz and Licensing Program Analysts (LPAs) Talwinder Bains and Cheyenne Ratajczak arrived at the facility unannounced on 11/28/23 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPAs and LPM met with Executive Director (ED), Stephan McDonald and explained the purpose of the visit. R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 10/20/23 regarding resident (R1) leaving the facility unattended on 10/12/23, at approximately 3pm. Per incident report, it was discovered R1 was missing from community on 10/12/23 around 1.30pm. Interviews indicated staff looked around for the resident but were unable to locate R1. Around 3pm, the police called the community stating they had located R1. R1 was found at their old house after R1s neighbors called the police. R1 was brought back to the facility uninjured by Executive Director, Stephan McDonald. LPA followed up with facility after this incident and gathered information for R1 including R1’s LIC602. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report, LIC602, dated 09/07/23 and R1s Needs and Service plan by facility, dated 09/23/23 indicates that resident has diagnosis of bipolar disorder and cannot leave the facility unassisted. R1’s AWOL Incident (2)- During record review, LPA observed that R1s charting notes by facility staff indicated that R1 had another AWOL incident on 11/01/23 where R1 went to local grocery shop by themselves on 11/01/23 around 1pm. Staff did not notice R1 was missing until R1 came back to the facility. This AWOL incident was not reported to the department as required. Although the facility has implemented safety precautions for R1 after their AWOL incident on 10/12/23, those measures were not effective since R1 left again unassisted on 11/01/23 which is a safety risk for R1. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted. In addition, the facility did not report R1’s AWOL on 11/01/2023 therefore not meeting reporting requirements. Violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report, appeal rights has been provided to ED.