Facility Evaluation Report

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management visit. LPA identified themselves to Sally Saif, Administrator we discussed the purpose of the visit.

Today's visit is in response to the AWOL of Client 1 (C1) date of incident: November 04 2024. The facility properly reported C1 going AWOL. The facility's Missing Persons/Absentee Notification Plan was reviewed on this date with the Licensee.

C1 was AWOL, C1 went outside of the the facility around 7pm to get some fresh air. C1 did not return to the facility. Around 2am the hospital called the administrator to let them know C1 called 911 and was on a hold due to suicidal ideations. C1 was released from the psych unit and returned to the facility on 11/05/2024.

Interviews and a record review revealed, C1 LIC 602 dated 10/07`2024 states they can now leave the facility unassisted, and C1 does have a history of AWOLing at this facility and prior facilities and it is documented on their Individual Program Plan (IPP). The facility did notify appropriate parties and took appropriate measures by notifying law enforcement upon C1 AWOL. LPA conducted interviews on this date. LPA received copies of pertinent information regarding C1.

No deficiencies were cited or observed on this date. According to interviews C1 will have a family visit for the weekend extended one day due to the holiday and the licensee will have C1 assessed medically for the suicidal ideations.

An exit interview was conducted with the Administrator. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Saif at the conclusion of the visit.