Incident investigation·October 19, 2022

Licensing Program Analysts (LPAs) Simi Rai and Steve Chang conducted a Case Management Incident visit, a continuation of a case management initially conducted by LPA Donovan on 5/10/22 regarding an incident which occurred on 4/21/2022 involved resident (R1). On 5/10/2022, LPA Donovan conducted interviews with staff at the facilty in response to an incident report that occurred on 4/21/22. According to ADM and staff, R1 was gardening in the backyard at 1:45pm. At 2:00pm staff did not see R1 in the backyard and went searching for R1. Administrator called the police to report a missing person. Police arrived at the home to take a report, when S1 called and reported S1 found. R1 was one block away. The police called 911 and R1 was transported to the hospital. R1 sustained injuries to face and hand. R1 was discharged back to the facility at 10:00pm with instructions to follow up with medical doctors. On 5/10/2022 stiches above right eye removed. R1 has neurocognitive impairment and no history of elopement. R1 was monitored by staff before the incident. After reviewing the available documentation, interview with administrator and S1 and S2's stating the timeline of the the incident, it is determined by the department that R1's elopement could not prove nor disprove that R1's elopement was due to staff neglect/lack of supervision. R1 was not neglected by the staff. This report was reviewed with Administrator Angelina Escobar and a copy provided. No deficiencies cited at this time.