Facility Evaluation Report

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conducted an unannounced case management deficiency inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Aurelia Olais and explained the reason for the inspection.

The regional office received an unusual incident report on April 1 st , 2025 regarding an incident that occurred on March 28 th , 2025. The report stated that Resident (R1) eloped from the facility and was brought back to the facility by police.

LPA toured the facility, gathered necessary documentation, and conducted interviews with Staff 1 (S1). LPA attempted to interview R1 but they were unable to recall the incident. During interviews S1 stated that R1 was last seen getting up from lunch around 12pm. Care staff noticed that R1 was missing when they went to do the routine rounds of checking on the residents. Care staff did not know the residents whereabouts for approximately an hour. S1 received R1 back at the facility around 1pm by police. Police informed S1 that he was found on the corner of the same street the facility was on. R1 was given a body assessment when returning to the facility by staff and no injuries were noted. Per doctors orders, medical assessment was not necessary but to monitor the resident closely. LPA tested the two delayed egress gates that lead outside of the facility and they tested operational with a quick response time from staff.

Upon file review LPA observed an in service training that was held the same day of the incident. LPA reviewed R1 physician report which states that they are unable to leave the facility unassisted. LPA reviewed monitoring logs done by care staff.