Facility Evaluation Report

Licensing Program Analysts (LPAs) Hiratsuka and Mikkelson, conducted this unannounced case management visit in response to investigating Complaint 59-AS-20241022104408.

-There are no audio alerts on the exits to the outside. Title 22 Regulations require audio alerts on all exit doors when exiting poses a hazard to residents. There are two residents who attempt to leave or have left the facility unnoticed and the audio alerts were turned off. Licensee stated the audio alert batteries die quickly so she put two chairs in front of the door and a wood rod in the sliding glass door (cited on complaint visit)

-A review of Resident (R1) needs and services plan it does not state the resident wanders outside and has left the facility a couple of times unnoticed by staff. There is no plan to address the resident attempting to leave the facility.

-A Review of Resident (R2) file, the needs and services plan has White-Out on it with R2's name handwritten on it but the plan itself mentions another person.

-A review of R2's file shows R2 does not have a pre-placement appraisal. Title 22 requires a pre-placement appraisal and annual appraisal.

-Licensee did not report R1 leaving the facility unnoticed by staff within 24 hours or by next business day by fax or phone call as required by Title 22 regulations. The resident leaving the facility unassisted meets the 24 hour notice because it threatened the health and welfare of the resident. The resident was found unharmed.