Incident investigation·May 22, 2025

On 05/22/25, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced at the facility to conduct a case management visit regarding an absent without leave incident report the department received via fax on 05/13/25. LPA met with Administrator, Darrel Price and explained the purpose of the visit. The incident occurred on 05/11/25 at approximately 9:30 AM when facility staff observed resident, R1 to be missing during rounds. Facility staff searched in the facility but was not successful. R1 returned around 11:30 AM and told staff that they went to church without notifying anyone at the facility with their roommate. Based on R1's ,LIC 602 Physician's Report, signed on 11/06/24 indicated that R1 was deemed unable to leave the facility unassisted. Record review indicated that R1 was residing at the facility since 05/03/24 and were on staff check list for hourly monitor prior to this incident. Staff stated that facility has increased R1’s safety check every 30 minutes/daytime and every hour /night time to ensure R1s health and safety after this incident. Facility notified R1s responsible party, physician and other required parties regarding this incident. LPA and administrator discussed having the appropriate number of staff to ensure the care and supervision of residents in care are being met. 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.