Facility Evaluation Report

On July 17, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit.

On July 5, 2024, the facility reported that during an outing at Brisbane Pier, resident #1 (R1) climbed over the barrier of the pier and jump into the water. Staff #1 (S1) was with R1 and tried to stop R1 from jumping but was not successful, therefore, S1 jumped into to the water and attempted to rescue R1. Subsequently, both of them were saved by the Coast Guard and R1 was sent to the hospital, and R1 was released on the same day. R1 returned to the program a couple of days later.

According to the administrator, R1's responsible party stated that R1 is a great swimmer, loves the water and has a tendency of jumping into the water whenever he/she sees the water.

The administrator stated that there is no change with R1's participation level at the program since the incident and the facility is following the directive of R1's responsible party of not brining R1 to any outings with water around. In addition, the facility provided in-service to staff to prevent this from happening again.

During today's visit, LPA observed R1 to be calm, and participating in exercise of choice.

This report is reviewed with the administrator. A copy is provided.