Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management visit and met with Administrator, Vicki Pacheco, Program Supervisor, Angelica Suud and Director of Quality Assurance and Compliance, Chris Mullins. The purpose of the visit was to obtain additional information on the multiple AWOLs reported to the Department.

During visit, LPA toured the facility to include the bedrooms, bathrooms, office, medication room, laundry room, kitchen, and backyard. All fire exits were free and clear of obstruction.

Between 07/29/2022 - 08/30/2022, the facility reported 4 AWOL incident reports to the Department. 3 out of 4 incidents occurred within the same week. All AWOL incidents were reported to law enforcement immediately, in which a missing persons was filed. 3 out of 4 incidents included a case number from law enforcement. Staff will follow-up with LPA on the case number not located for R4 by 09/12/2022.

Facility is a short-term voluntary program. Staff cannot force the clients to stay at the facility if they choose to leave, but staff encourage and persuade the clients to continue the program, as best as they can. LPA reviewed the facility's procedures for the certain incidents reported. If a client AWOLs, the facility has a procedure to contact law enforcement immediately, appropriate teams / agencies, and the client's conservator and responsible party, if applicable. If a client AWOLs, the facility will hold their bed for a certain amount of time. Staff has a procedure for clients who want to leave the facility Against Medical Advice (AMA).

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Vicki Pacheco, Angelica Suud, and Chris Mullins and a copy of the report was provided.