other·October 13, 2021

During the course of investigation, LPA obtained copies of resident roster, staff schedule and reviewed R1’s documents including but not limited to Physician’s Report, hospital discharge documents, appraisal, hospice care documents, Facility Service Notes, lists of medications, Admission Agreement and Power of Attorney. LPA also obtained copies of police report and medical records, and conducted interviews, Two of the staff interviewed indicated R1 has wandering behavior and was able to leave the facility unnoticed. Staff indicated they came to know R1 was missing when the caregiver asked where R1 was. Staff drove around and searched but was unsuccessful. They called law enforcement and reported R1 was missing. R1 was found by bystander who called 9-1-1. Facility records and medical records showed R1 has dementia. Medical records further revealed R1 sustained right zygomatic arch, right orbital wall, right maxillary wall, and left maxillary wall fractures, and right middle finger avulsion fracture resulting from fall. Based on the information gathered, the allegations are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 California Code of Regulations (see 9099D). A $500.00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty. Deficiency, plan and proof of correction and civil penalty were discussed with Diane Pederson,. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.