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25 | On 12/23/2024, the Licensing Program Analyst (LPA) Yi Sam Jian arrived at the facility for an unannounced case management visit to follow up on an incident report submitted by the facility to the department on the same day. The report indicated that on 12/22/2024, R1 had left the facility, missed both breakfast and lunch, and suffered a fall outside. R1 was taken to St. Mary’s Hospital and returned to the facility by 2:00 PM on 12/22/2024, back to baseline. The LPA met with the Administrator, Anna Villanueva-Aoay, and explained the purpose of the visit.
Upon reviewing R1’s records, the LPA found that R1 is ambulatory. The Appraisal/Needs and Services Plan noted that R1’s physical health is to enjoy walking outside at baseline. The Physician’s Report indicated that R1 is "able to leave the facility unassisted" with no reported "wandering behavior." The Physician has cleared R1 to leave the facility unassisted. The Client Assessment Checklist in the admission also noted that R1 does not have an AWOL risk or wandering tendencies. During an interview with the Administrator, it was confirmed that R1 enjoys going outside for walks, and R1 did not suffer any major injury from the fall occurred outside the facility.
During the visit, the LPA observed that staff were actively monitoring the front door, and staff was signing in and out all individuals entering and exiting the facility.
No deficiencies were cited. This report was reviewed and discussed with the Administrator, and a copy was provided.
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