Facility Evaluation Report

On 4/10/23 at 9:01 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - other inspection. LPA explained reason for inspection and met with John Noriega, Director of Client Services (JN). Administrator (ADM) Rhonda Glenn was not available for the inspection.

LPA asked if S1 was presently working in the facility. JN pulled the staff schedule and it was observed that S1 was not listed as a scheduled employee. After further investigation, it was determined that S1 may have been placed through the hiring process but was not hired and/or never worked in the facility. JN advised JN was not familiar with named S1. LPA informed JN that there is a Decision and Order excluding S1 and S1 is not allowed to be present in the facility or have contact with any clients. A Civil Penalty will be assessed if S1 is found to be working or present in the facility. LPA advised JN that S1 will need to be removed from the facility roster.

CCL received Special Incident Reports (SIRs) from the facility concerning two separate AWOL incidents that occurred on 10/19/22 and 11/3/22. LPA investigated both incidents. On 10/19/22, C1 eloped from the facility two times but was shadowed by staff during both elopements from the facility. On 11/3/22, C2 eloped from the facility. It is unknown exactly how long C2 was missing before S2 discovered C2 missing. S2 immediately notified the manager and several staff were sent to look for C2. Approximately 45 minutes later, the facility was called by a nearby medical office to report C2 was there. JN picked C2 up from the hospital 6 minutes later. C2's Physician's Report shows C2 cannot leave the facility unassisted. C2's Individual Program Plan (IPP) shows C2 has a history of elopement.

A deficiency is being cited based on LPA's record review and interview conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with JN. A copy of this report and appeal rights were discussed and left with Director of Client Services John Noriega, whose signature on this form confirms receipt of these documents.