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: 09/02/2025. The facility properly reported C1 going AWOL. The facility's Missing Persons/Absentee Notification Plan was reviewed on today's date with the Licensee.

On 08/27/2025 C1 went AWOL. Interviews revealed that a round 8pm, C1 stated that they didn't feel well and stated they wanted to "Get fresh air". Interviews revealed that staff stayed with C1 outside when C1 stated that they are getting agitated and doesn't feel well. Staff called the administrator and described the situation and stated that they went out to check on C1 again outside, and C1 was no where to be found, Staff looked everywhere and around the facility as well as the back and front yard and there were no signs of C1. Interviews revealed that the staff waited 10 minutes and checked again and then called 911 to report C1 missing. According to C1s physician report they are able to leave the facility unassisted and they have community access plan. Interviews revealed that C1 was found in their room on 8/28/25 at 5am. Interviews revealed while they were assessing the client they reported that they were at Paradise Valley Hospital and that they called the ambulance for abdominal pain. No other information or papers were provided to staff from C1.

A record review revealed, C1 LIC 602 dated 10/07/2024 states they can 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. An exit interview was conducted with the Administrator. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) was provided to Saif at the conclusion of the visit.