Facility Evaluation Report

Licensing Program Analyst (LPA) Rayshaun Nickolas arrived at facility for a Case Management Visit. LPA met with Administrator Ernest Montes. Purpose of visit was to present licensee with findings following the Department investigation of the death of C1.

On November 17, 2021, the licensee reported to the Department that C1 was absent without leave (AWOL) from the facility. C1 was later struck by a vehicle. C1 passed away as a result of injuries sustained from the accident. On November 19, 2021, the Department conducted a Case Management Visit to the facility. On that date, Department staff collected pertinent records of C1.

The investigation of C1’s death consisted of records review and interviews with relevant parties. C1 was admitted to the facility around August 16, 2016. Upon admission, C1 was identified as ambulatory. C1 was known to have a history of AWOL behavior.

Individual Program Plan (IPP) for C1 dated March 8, 2021, indicates that C1 is to have one to one supervision (line of sight). In addition, staff records show training completed in regard to C1 supervision needed.

Prior to AWOL on November 16, 2021, C1 was last observed going into the restroom. Interviews with multiple facility staff, including Staff #1 (S1) and Staff #2 (S2), as well as other pertinent individuals was conducted. Those interviewed confirmed acknowledgement that C1 required one to one supervision at all times. Facility staff were also aware of C1’s propensity to AWOL. On November 16, 2021, facility staff did not observe C1 after C1 exited the restroom. S2 also acknowledged that facility staff did not maintain a line of sight of C1, and as a result, C1 was able to leave the facility without supervision.