Facility Evaluation Report

On 07/27/2022, Licensing Program Analyst (LPA) T. White conducted an unannounced case management visit to follow up on an AWOL incident resulting in client death, which occurred on 07/24/2022. LPA met with Adriana Palacios, Case Management Supervisor and Janine Herera, Clinical Supervisor. LPA explained the purpose of the visit.

Based on incident report on 07/24/2022, at 6:30 PM Client #1 (C1) left the facility unauthorized. Staff followed and encouraged C1 to return to the facility. C1 returned to the facility with staff at approximately 6:49 PM. Upon return, C1 immediately fled the facility again. Staff immediately followed loosing sight of C1 a block away from the facility. Staff conducted a search surrounding area. Staff immediately followed C1 who began sprinting and could not locate a short while after sprinting. During search, staff were alerted to several officers in a nearby alley surrounding a home. Staff were told by police to stand down. During police and client interaction, staff were notified by police that C1 had passed away. Based on staff interviews, staff are unsure how C1 passed away. Facility will request police report regarding incident.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties.

Exit interview was conducted with Case Management Supervisor and . A copy of report given and Appeal Rights given.