Incident investigation·November 13, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Rebecca “Becky” Rayo. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 11/07/2023). According to the LIC624, during the late evening of 11/06/2023, Resident #1 (R1) left the facility without informing staff or signing themselves out on the facility's logbook. [See LIC 811 Confidential Names List for a description of C1.] During today’s visit, LPA performed a brief facility tour and interviewed R1 (who had since returned to the facility), finding they were unharmed. LPA also collected copies of pertinent care records, and interviewed relevant staff and R1's roommate. According to R1’s latest LIC602 Physician’s Report (dated 06/27/2023): R1 was diagnosed with “Schizophrenia, bi-polar type,” but did not have Dementia or cognitive impairment. Their doctor determined that R1 was able to follow instructions, able to communicate needs, and “able to leave the facility on [their] own and return on [their] own.” R1 was also independent in all Activities of Daily Living (ADLs), except for medication assistance. R1’s independence with personal care was also evidenced in other facility and third-party care records. R1's Facesheet also showed that they were their own Responsible Person (RP). [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809-C] Interview of R1, their roommate, and staff, corroborated by dated and written progress notes, showed: During the 11/06/2023 incident, R1 left the facility without telling staff or signing themselves out on the logbook, as was required in the House Rules with R1 signed upon admission. Facility staff provided needed observation and timely recognized that R1 was not present during a routine room check. Staff followed the facility’s Absentee Notification Plan and timely notified law enforcement and R1’s psychiatrist. Around 24 hours later, R1 had returned to the facility on their own, unharmed. During review of the facility’s care records on R1: LPA observed that while R1 had a completed LIC9172 Functional Capabilities Assessment, the LIC603 Pre-Placement Appraisal which Licensee performed on R1 was incomplete (several missing fields). LPA also observed that R1’s LIC625 Appraisal/Needs and Services Plan was blank and not signed. Interview of the administrator confirmed that R1 was referred to the facility by their assigned psychiatrist, but the Licensee or their staff did not personally meet with R1 prior to move in, for the purpose of completing an independent, pre-admission appraisal interview. One (1) deficiency was thus cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Rayo, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.