Incident investigation·May 8, 2024

On 5/8/2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 5/6/2024. LPA met with Med Tech, and explained the purpose of the visit. During today's visit, Administrator and Residential Care Director was unavailable. LPA spoke with Residential Care Director via telephone during LPA's visit to conduct interview and explain the purpose of the visit. The incident occurred on 5/5/2024 at approximately 1:30 PM when facility staff observed R1 to be missing during rounds. Facility staff then contacted Residential Care Director, who then found R1 "a few blocks from facility" with alcohol and was observed to be impaired beyond baseline. Based on R1's LIC 602 Physician's Report, signed on 2/18/2024, indicated that R1 was deemed unable to leave the facility unassisted. LPA and Residential Care Director discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met. Additionally, LPA and Residential Care Director discussed this incident may have been a new placement trauma which caused R1 to flight. Residential Care Director stated a conference call be made to elaborate the reasoning why R1 is unable to leave facility unassisted. As a result of the incident, deficiencies cited. Please see LIC 809-D, per Title 22 Regulations. Exit interview conducted, a copy of the report and appeal rights provided to facility staff. Signature on these forms acknowledges receipt of these documents.