Incident investigation·October 20, 2023

On 10/20/23 at 1:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a case management regarding an AWOL incident which occurred on 10/13/2023. LPA Lee met with direct care staff, Dillon Williams, who then called administrator, Salote Lewis to informed that Community Care Licensing Department (CCLD) is present in the facility. LPA Lee explained the purpose of the visit. The census is 4 resident with one facility staff. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. At 2:00 PM, LPA Lee toured the facility with direct care staff, Dillon Williams, to ensure the safety of the residents. LPA interviewed direct care staff, Dillon and reviewed incident report dated 10/16/2023. LPA Lee also reviewed (R1) LIC 625, Needs and Services and LIC 602 Physician's Report. Based on interview and record review it was determined that R1 exited the facility front door on 10/13/2023. Moreover, it was also learned that while staff 1 (S1) was doing rounds to check on the residents (S1) did not see (R1) in (R1) room or anywhere in the facility. Law enforcement was called, and a missing person report was filed. R1's LIC 602, Physician Report dated 09/25/2023 was reviewed by LPA Lee and it revealed that (R1) is unable to leave the facility unassisted. Interview with Administrator revealed facility's internal plan includes providing supervision for R1 and all other residents in care. Additionally, it was revealed through interview that R1 left the facility, and no facility staff was aware of (R1) whereabouts. It was also discovered that (R1) was approximately 0.8 miles away from the facility when law enforcement found (R1) and brought (R1) back to the facility. 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 issued in addition to citation due to absence of supervision. An exit interview was conducted with direct care staff, Dillon Williams. A copy of this report LIC 809, LIC 809-D and appeal rights was provided to direct care staff at the end of the visit.