Facility Evaluation Report

On 10-30-23 at 10:15am, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to conduct a case management visit regarding a previous absence without leave (AWOL) incident. LPAs met with lead caregiver Flordeliza Agtang and explained the purpose of the visit. LPA Bilger spoke with Administrator Marivic Teano-Chua by phone and explained the purpose of the visit. LPAs conducted brief interviews with staff1 (S1) and S2. LPAs also reviewed incident report dated 10-12-23 as well as physician's report for resident1 (R1), needs and service plan for R1, and care notes for R1. LPA's conducted a brief facility observation. This observation revealed facility has 8 rooms available for residents and a sign in, sign out sheet is established for resident use. Based on interview and record reviews, it was determined that on 10-11-23, facility staff was conducting rounds at approximately 2:00am and discovered R1 was not in bed or bathroom. Facility staff attempted to locate R1 by searching throughout facility and driving to nearby stores and parks in the area. Facility staff also contacted local law enforcement to file a report, and law enforcement arrived at facility at 2:45am to gather additional details. Licensing department was notified of incident within regulatory time frames.

Upon further record review and interview, it was revealed that on 3-3-23, R1 had a previous attempt to AWOL from facility but was successfully redirected by staff. Additionally, it was revealed that facility did not utilize an internal plan of action to help mitigate potential further occurrences of AWOL for R1 given R1's history of attempting to AWOL. Physician's report states R1 is allowed to leave unassisted, however, R1 did not utilize the sign in and sign out procedure established further resulting in an absence of supervision on 10-11-23. Facility was unaware of R1's whereabout until 10-13-23 when local hospital notified facility staff that R1 was residing in the hospital after being found unresponsive on 10-11-23 at 4:52pm.

As a result of today's case management, citation is issued under Title 22, Division 6 and noted on 809D. A civil penalty in the amount of $500 is issued in addition to the citation due to the occurrence of absence of supervision. An exit interview was conducted with Flordeliza Agtang and a copy of this report was provided to Flordeliza. Appeal rights provided.