Facility Evaluation Report

On 8/25/2023 at 02:25pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a case management visit. This a follow-up visit pertaining to a questionable death of a client who passed away on 10/08/2022. On 10/08/2022, Client 1 (C1) eloped from the facility. Staff failed to adequately supervise C1, leading to him being shot in the community which caused his death. LPA met with Ovilio Barrios Garcia, Administrator and explained the reason for the visit.

The Department’s investigation included but was not limited to interviews with current staff, witnesses, clients, and the collection and review of records from the facility and Antioch Police Department (APD).

Client 1 (C1) was admitted to the facility on 8/21/2022. It was noted on C1’s post placement Individual Service Plan (ISP), dated 8/18/2022, that C1 was an elopement risk, and exhibited verbal and physical aggression behaviors. The facility requested C1 to have a 1:1 staff. The Department received confirmation from the Regional Center of the East Bay (RCEB) that approval was given for the 1:1 effective 8/21/2022 to 2/28/2023. During record review the Department reviewed incident report dated 09/19/2022 which indicates C1 eloped, but staff was able to follow C1. The incident report dated 09/27/2022 indicates C1 eloped from the facility without staff knowledge.

Based on interviews and documentation, C1 had a history of failing to follow staff orders or house rules. Staff stated C1 would often become angry and verbally aggressive towards staff if they tried to implement the rules. C1 also had a history of leaving the facility without permission and without supervision by leaving through his bedroom