Facility Evaluation Report

On 09/23/2022 at 9:45am, Licensing Program Analyst (LPA) Arielle Pascua arrived at the facility unannounced to conduct a case management visit. LPA Pascua met with Michelle Nekrawesh and explained the purpose of this visit. The purpose of this visit was to conduct a case management visit to follow up on an incident report that was sent into the department on 09/16/2022 regarding Resident 1's (R1) AWOL from the facility. At 9:50am, LPA Pascua asked, staff member, Nekrawesh to call the Administrator to inform them that CCL was present at this time. There were three other staff members present, Toribio Castro, Jazmin Virrueta, Iman Nekrawesh.

LPA Pascua reviewed the SIR and the LIC 602 for R1. It was learned that R1 is not permitted to leave the facility without assistance. LPA Pascua requested a copy of the IPP for the client R1 for review. It was learned through review of R1's IPP that the resident has a behavior in wandering and is currently working on mitigating that behavior.

From 9:50am-10:00am brief interview with Administrator, Jessica Dizon was conducted via telephone. Based on interview with AD, Dizon, it was also learned that R1 has known wandering behavior prior to admission to this facility. AD, Dizon stated that she has already been in multiple meetings with Valley Mountain Regional Center and R1's service coordinator about R1's wandering behaviors. R1 has also worked with behaviorist to find solutions to help mitigate the behavior. An upcoming IPP meeting is scheduled for sometime next month to discuss continuing behaviors being demonstrated.

Based upon interviews and documentation reviewed and received, no violations or deficiencies have been issued during today's visit.

Exit interview conducted with Toribio Castro, a copy of the LIC809 was provided upon exit.