Facility Evaluation Report

On 1-30-24 at 1:26pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for incidents regarding care and supervision and medication procedures. LPA met with Administrator Danica Morrison and explained the purpose of the visit. LPA conducted brief interview with Administrator.

Incident #1: Based on incident report dated 12-29-23, resident1 (R1) eloped from facility on foot at 6:15am. Facility staff followed R1 on foot and using the facility van. During this time, R1 ran away from staff towards nearby train tracks. Law enforcement was notified and offered assistance. R1 was found at approximately 7:20am and taken to local acute hospital for evaluation. Based on incident report and interview, it was determined that R1 was without staff supervision for approximately 30 minutes during this AWOL incident.

Incident #2: Based on incident report dated 1-26-24, facility staff was conducting an end of shift medication count for resident2 (R2). A medication, Guanfacine 1mg was indicated on the medication log sheet to have been passed on 1-26-24 during the morning shift, however, R2's bubble pack was observed by facility staff on evening shift to have shown this medication was not given, resulting in R2 missing the morning dosage.

As a result of today's case management, citations are issued under Title 22, Division 6. A civil penalty in the amount of $500 is issued in addition to the citation due to absence of supervision. An additional civil penalty in the amount of $250 is issued in addition to citation due to a repeat violation of Section 80075(b) within a 12-month period. An exit interview was conducted with Danica Morrison and a copy of this report was provided to Danica. Appeal rights provided.