Facility Evaluation Report

On 12/9/2022, LPA Tryon visited the facility to follow up on an Incident Report dated 12/3/2022. On that date, Resident R1 was able to leave the facility unattended, and was brought back home by Roseville Police. The staff was not aware that R1 was gone until the police brought him home. In reviewing resident's Physician Report, it was learned that R1 is not able to leave the facility unassisted, and has a history of wandering behavior

LPA met with House Manager Delson Bautista. We discussed the events around the Elopement. The staff stated she had checked on R1 between 8:00 p.m. and 9:00 p.m. and he was in his room. At about 10:00 p.m. the police came to the door and returned R1 home. She had not been aware that R1 had left.

The staff involved is no longer working at the facility.

Staff level has been increased to at least 2 staff present morning, afternoon, and NOCs. Sometimes, there will 3 staff present. The home is doing a refresher course for incidents, including training on AWOLS and how to work with clients. A new alarm system is scheduled to be in stalled on December 19.

At this time, it appears that staffing was not adequate to ensure that residents were safe, as R1 was able to leave without being noticed.

The following deficiency is cited as per Title 22 Regulations. Appeal Rights provided, Exit interview conducted.