Incident investigation·September 30, 2024

On 9/30/2024 at 1:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to the incident report that was received on 8/29/2024. LPA met with Executive Director, Harmony Venturelli and explained the reason for the visit. Based on the incident report received on 8/29/2024, resident (R1) was found by a neighbor down the street and was brought back to the facility by police. During visit, LPA reviewed R1's file including physician's report, care notes, care plan, and incident report. R1's physician's report and care plan indicated that R1 has a history of wandering behaviors and R1 cannot leave the facility unassisted. Interview with staff revealed that when delayed egress alarm went off, S2 went outside and didn't see any residents outside. When a head count was conducted, R1 was found to be missing. The deficiency was observed (see LIC 809D) and cited from the Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.