Facility Evaluation Report

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Business Office Manager Rebecca Toves. LPA also met with Executive Director Emily DeLaBarre, who arrived later during the visit.

Today's visit was in response to a self-reported LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 03/27/2023. Per the report: on 03/20/2023, Resident #1 (R1) had an AWOL (absent without leave) incident. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Facility staff did not see or hear R1 leave. Upon recognizing R1 was missing, staff unsuccessfully searched the facility building and surrounding areas before calling law enforcement. R1 was found a few hours later by personnel at a neighboring business, who returned R1 to the facility unharmed/uninjured.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA interviewed R1 and relevant staff. LPA also reviewed pertinent administrative, care, and medical records.

According to R1’s latest LIC602 Physician’s Report (dated 02/01/2023), to the stock question about whether R1 was “able to leave the facility unassisted,” their doctor checked “yes.” However, the same doctor also diagnosed with R1 with “Mild Cognitive Impairment,” indicated they were wheelchair-dependent, and noted they could not independently manage cash or medications. Manager interviews confirmed that prior to the incident in question, R1 was assessed as not able to safely leave the facility unassisted. During interview, LPA observed that R1 was wheelchair-bound and disoriented to time and place (i.e., R1 was unable to state the city they were in, unable to state the year, and unable to name the U.S. President). Due to their baseline disorientation, R1 was not able to participate as a reliable historian/interviewee in this investigation.