Incident investigation·September 23, 2021

Licensing Program Analyst Lopez and Canela arrived unannounced for the purpose of following up on an incident involving a self reported incident submitted to Community Care Licensing (CCL). On 9/7/2021 a resident went AWOL from the facility. LPA met with Administrator, Melody Lee-Allmond and reviewed records. Physician's report indicates that the resident cannot be in the community without assistance from the staff. It was reported R1 went into another residents room, climbed over the air conditioning unit that was against the window, cut the screen with a key that was in his possession and climbed over the widow and got out. Vacaville Police department was notified and searched for the resident, it was reported the resident may have used some chairs that were in the parking lot yard of the facility to climb over the wall and exit the grounds. Facility explained they have never had an incident were a resident has actually cut through the screen of a window to get out. All windows and screens have alarms to alert staff, but when the resident cut the screen the alarm was not able to alert staff. Facility conducted a check of all resident bedroom windows to ensure they are all in working condition and immediately removed any chairs from the parking area. Residents do not have any access to the facility parking lot, the resident gained access to this area when R1 broke the screen and climbed out. Facility moved the resident to a different unit where he would be more engaged to meet his needs and placed him on 15 minute checks until he became more familiar with this facility. R1 was said to be doing well, family and physician were notified of the incident. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with , Melody Lee-Allmond and appeals right given