Facility Evaluation Report

11/30/2023 11:00 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Tonya Foster. Today’s visit is regarding an incident that occurred on 11/20/2023 and was reported to licensing the same day.

It was reported that on 11/20/2023 Client 1 (C1) was in their room watching television and went to ask Staff 1 (S1) for a cigarette. S1 grabbed the cigarette and lit it for C1 outside. While C1 was sitting outside they eloped past the boundaries of the facility. S1 followed C1 but stayed on the facility property and called the on-call staff. The staff was able to maintain visual of C1 until C1 walked down the road towards a curve. The On-call Staff 2 (S2) located C1 very soon after. S2 observed a man with a gun in one hand and a flashlight in the other stating that he was a police officer and he was going to shoot C1 because they were breaking into the man’s house. S2 quickly got C1 into the vehicle and shut the door. The man continued to yell at C1 while the S2 apologized for the disturbance. C1 was taken home and was stable for the remainder of the night.

During the course of the investigation, it was learned that C1 is known to frequently elope from the facility and attempt to make contact with neighbors by knocking on doors in the early hours of the morning. The facility was issued a citation on 6/25/2021 by the department due to C1 eloping from the facility. At that time the department required the facility to increase staffing for the graveyard shift to ensure that two staff were on duty. During the current incident staff had called out and this left one staff on duty during graveyard shift which prevented staff from being able to leave the facility and follow C1 when they eloped from the facility which placed C1 in grave danger due to the response from the neighbor.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Tonya Foster.