Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/28/22 at 9:15AM. LPA met with Jennell Revera, Administrator and stated the purpose of today’s visit. Community Care Licensing (CCL) received an Incident Report (SIR) on 4/26/22 indicating that resident #1 (R1) left the facility without the knowledge of the staff.

LPA requested, received and reviewed the most recent Physician Report (LIC602) for R1 dated 1/5/21. The LIC602 stated that R1 was unable to leave unassisted and has a diagnosis of Dementia.

A review of R1's most recent assessment Individual Service Plan (ISP) dated 4/22/22 indicates that R1 utilized a wander guard that would be checked daily. It also indicated that R1 had a supervised elopement on 4/12/22 and an elopement on 4/22/22 during night shift.

LPA conducted interviews of Staff #1 (S1) - (S5) and family of R1 during this visit. LPA received information that R1 eloped previously on 4/22/22. Administrator stated that the incident was not reported.

Per the Administrator and the most recent assessment, effective 4/22/22, R1 was to receive 1:1 supervision during (NOC) shift hours of 10p-6am due to wandering behavior but the agency cancelled the shift at the last minute. Staff #2 (S2) was put in place for the 1:1 companion to ensure the supervision of R1.

LPA toured the facility with Administrator. LPA observed with Administrator and S3 that the door did not alarm when pushed opened outward. S3 does a weekly check on day mode and now conducts weekly checks on night mode as well.

LPA observed the room where R1 reside and the area that S2 was located to observe R1. Administrator stated that S2 did not look into R1's room as to be careful not to wake R1 as any disturbance would cause R1 to be awake all night.