complaint·July 19, 2023

On 5/23/2022, R1 wandered away from the facility. Based on the call record provided by RP, RP was informed about the incident at around 6:33 pm. RP was told by facility that R1 was observed missing at around 4:45 pm. At around 6:38 pm, RP states that a friend texted RP about R1 spotted around Niles area of Fremont which is approximately 4.4 miles away from the facility and has a walking time of approximately 1hr and 36 minutes. At around 7:15 pm, RP found R1 near the corner of Mission Blvd and Walnut Avenue in Fremont. A copy of Union City Police Department Everbridge Nixles missing person report was obtained and indicates that the incident was entered on 5/23/2022 at 7:41pm. A review of facility’s three internal incident reports confirm that R1 wandered away from the facility on May 23, 2022. Staff are mismanaging resident's medication LPA L. Fontanilla obtained and reviewed R1’s April - May 2022 Medication Administration Record (MAR). April 2022 MAR indicates R1 was on Donepezil from April 22-30. For the month of May, R1 was given the medicine on May 3,4,7,8,9,11-14 for a total of (9) days only. Based on records review conducted, the above allegations are substantiated. Based on record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations Title 22 are being cited on the attached Lic 9099D Exit interview was conducted with Director and Appeal Rights was provided. Resident’s room has pests During the course of investigation, LPA interviewed Robert Roby. He states the facility has a contract with Ecolab Pest Control. On 7/19/2023, LPA inspected four rooms in the Memory Care Unit and did not observe any pests in the rooms. MCD denied seeing any pests in any of the rooms in the Memory Care Unit. Based on observation and interviews conducted, the above allegations are unsubstantiated . Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.