Facility Evaluation Report

On 3-27-23 at 10:45am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident reported on 3-7-23. LPA met with program director Sherry Welker-Loza and explained the purpose of the visit. Incident report and physician's report was reviewed with program director. Incident report states that on 3-7-23 at approximately 2:00pm, resident1 (R1) and his group were in route back to the day program on a city bus. R1 and his group arrived at their schedule bus transfer and R1 remained on the bus unsupervised, which resulted in an absence of supervision. At approximately 3:00pm, R1 notified his care home staff of his location, who in turn notified day program of R1's whereabouts. Day program staff then arrived at R1's location and transported him back to day program.

Day program staff began searching for R1 immediately upon learning of R1's absence of supervision. Day program reported incident accordingly and per regulatory requirements. Physician's Report reviewed states R1 is unable to leave facility unassisted.

As a result of today's case management, citation is issued under Title 22, division 6. An immediate civil penalty in the amount of $500 is issued in addition to the citation due to absence of supervision. An exit interview was conducted with Sherry Welker-Loza and a copy of this report was left with Sherry. Appeal rights provided.