Facility Evaluation Report

Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced case management and met with Curtis Mixon - staff. Sheri Lott - supervisor wasn't able to arrive for this visit, however; LPA spoke on the phone regarding concerns. The purpose of the case management visit was to obtain additional information regarding incident reports submitted to the Department.

Department learned that on 11/15, 11/16, & 11/29/2021 client C1 left the facility unassisted and on 10/29 & 11/7/2021 client C2 also left the facility unassisted. In all occasions clients C1 & C2 were found and came back to the facility. Client C1 physician's report dated 10/20/21 states that client has a diagnosis of intellectual disability; Client C2 has no physician's report on file with admissions agreement to the facility dated 9/16/2019. According with physician's report for client C1, client is not allowed to leave facility unassisted and client C2 facility staff stated that C2 is not allowed to leave facility unassisted. (see copies, LIC 809-D) LPA asked questions and requested more information regarding facility procedures for clients that are not able to leave facility unassisted. Per staff, facility has awake staff 24 hrs/ 7 days a week. In addition, client C1 is known for this behavior and staff is supposed to check on C1 periodically. Both clients bedrooms have sliding doors that open to a deck that leads to outside. There is no gate on the premises once clients open sliding doors.

In addition, LPA learned that client C2 with admissions on 9/16/2019 has no physician's report and/or TB test results on file. Facility staff Sheri Lott stated that facility hasn't been able to acquire a physician's report/medical assessment for client. Title 22 Regulations # 80069(b) states that " In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment."