Incident investigation·January 14, 2025

On 01/14/2025 at 1:50 PM Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced Case Management visit regarding information obtained that a resident was missing from an Unusual Incident Report (UIR) received on 1/6/2025. LPA met with Administrator, Ferdinand Gutierrez and explained the purpose of the visit. LPA K. Nguyen interviewed S1 that confirmed that R1 was missing on 1/03/2025 and returned back to the facility on 01/07/2025. S1 stated that R1 leaves almost every day since R1 were admitted which was 08/5/2024. However, on this particular day, R1 did not return. S1 stated that R1 went to see R1 husband in Oakland without informing any staff. R1 had a court order that R1 husband are not to be near R1, and R1 husband are not supposed to be at the facility as well. S1 stated that R1 is trying to find ways to see R1 husband. We cannot stop R1 from leaving the facility. LPA interviewed R1 and R1 stated that R1 went to see R1 husband because R1 haven’t seen R1 husband for 3 months. R1 stay at R1 husband house, and R1 husband brought R1 back to the facility. R1's Physician's Report indicates that R1 are able to leave the facility unassisted. LPA reviewed R1 files and confirmed R1 physician report that R1 is able to leave the facility unassisted. No deficiency issue on today date. Exit interview conducted and a copy of this report is provided.