Facility Evaluation Report

On 4/28/23 at approximately 9:30am Licensing Program Analysts (LPAs) Maja Jensen and Jennifer Fain arrived at facility unannounced to conduct a case management for a report related to a resident that left the facility unsupervised. LPAs Jensen and Fain met with Licensee Justice Ehimamiegho and explained the purpose of today's visit.

LPA Jensen was notified by local law enforcement that on 4/20/23 at approximately 4pm, resident 5 (R5) left the facility unsupervised. R5 was not reported missing until 08:23am on 4/21/23. At that time law enforcement canvassed the neighborhood and located the resident.

LPA Jensen also reviewed an incident report sent on 4/22/23 that indicated R5 left the facility on 4/20/23 after dinner and did not return until the next day after being found by the police.

LPA Jensen reviewed staff care notes that indicated R5 left the facility but no specifics were noted on where the R5 was going or when she would be back. LPA Jensen reviewed the resident sign out log and observed that R5 had signed out but there was no time of sign out or destination noted.

Deficiencies are being cited from the Health and Safety Code (HSC), Title 22, Division 6. An immediate $1000 civil penalty is also being assessed. Failure to correct deficiencies may result in additional civil penalties and administrative action.

An exit interview was conducted and a copy of this report was given.