Incident investigation·August 30, 2023

Licensing Program Analysts (LPA) Dang Nguyen and Amy Rodgers conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Caregiver Nanita Abat. LPAs also spoke with Administrator Bessie Pascual, who joined a portion of the visit via phone. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 08/28/2023). According to the LIC624: during the morning of 08/25/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] Police located R1 unharmed and returned them to the facility, later the same morning. During today’s visit, LPAs performed a facility tour and welfare check. On the date of LPAs’ visit, R1 was off-site at a skilled nursing facility (for separate health reasons, not a result of the elopement). R1’s housemates were safe. LPAs also reviewed pertinent facility care records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 06/08/2023), R1 was diagnosed with schizophrenia and intellectual disability (among other diagnoses), and their doctor determined that they were not able to safely leave the facility unassisted. Staff interviews, corroborated by care records, showed: R1 was able to toilet, bathe, and dress themselves independently. R1 had not eloped or attempted to elope from the facility prior to the incident in question. On 08/25/2023, Staff #1 (S1) observed R1 use the shower at 1:00 AM, and then use the bathroom at 3:00 AM and 4:00 AM, respectively. Around 5:15 AM, S1 observed the facility’s kitchen door was left open, and first recognized that R1 was not present inside the facility. S1 notified the administrator, who joined the search for R1. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Not having located R1, the administrator phoned San Diego Police Department (SDPD) around 8:30 AM to report R1 as a missing person. Around 9:45 AM, a bystander encountered R1 at bus stop in another city and recognized that R1 needed help. With this tip, SDPD picked up R1 and returned them to the facility unharmed around 11:56 AM. Record review, corroborated by manager interview, showed: Licensee did not develop and maintain a written Absentee Notification Plan as part of the written record of care for 5 of 5 current residents in care (R1 through R5). One (1) deficiency was thus cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPAs also issued Technical Assistance (TA) regarding installing staff auditory alert devices on the facility's perimeter/exteriour doors. An exit interview was conducted with Pascual via phone. A copy of this report, the LIC809-D, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to her via E-mail, during the visit.