Facility Evaluation Report

Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced case management visit. This case management visit was regarding an elopement incident on 9/5/2021 involving client (C1). LPAs met with Administrator (ADM), Rosa Sanchez.

On 9/5/2021 around 4:00pm, C1 had left the facility without authorization and returned around 6:00pm. C1 did not notify staff upon his departure and upon his return. On 9/8/2021, C1 had a scheduled doctor’s appointment and a random drug test screening was conducted. On 9/15/2021, facility received notification of a positive drug test result. ADM spoke with C1, wherein C1 admitted of leaving the facility without authorization and purchasing drugs. The facility was not aware of the elopement until the notification of the positive drug test results.

On 9/17/2021, LPA Dolores spoke to ADM via telephone and ADM stated staff did not conduct 30-minute routine checks according to the program plan.

On 10/6/2021, LPAs interviewed C1. C1 confirmed the facts of the incident.

LPAs reviewed C1's physician's report and appraisal/needs and services plan. C1's physician's report stated that C1 is not able to leave the facility unassisted. Facility records review noted 2 staff on duty were given disciplinary actions for failing to conduct 30-minute checks.