Incident investigation·January 10, 2023

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to information received from Adeliza Magalonnes. Magallones submitted a copy of facility's Narrative Report for resident (R1) indicating R1 AWOLed on 12/30/22. LPA responded to Magalonnes informing her to use the Departments' LIC624 Unusual Incident Report (UIR) when reporting an incident and requested for copy of LIC602A Physician's Report. Report indicated that at 4:15 am on 12/30/22, R1 was found not in R1's room. Staff searched the facility and neighborhood and called the police. R1 was found and returned to the facility by the police officer. On this day, 1/10/23, LPA met with Celeste Olivarez, facility consultant, and staff, Maria Dolores Floriza, and informed the purpose of visit. John Olivarez, licensee, arrived after about an hour, Review of R1's LIC602A Physician’s Report revealed R1 has dementia, confused/disoriented, has wandering and sundowning behaviors, needs assistance with bathing. dressing and grooming. However, LIC625 Appraisal/Needs and Services Plan not updated to reflect and meet R1's current needs, LPA conducted interviews, and obtained copy of LIC Personnel Report. LPA conducted inspection with Olivarez and Floriza. LPA checked the front door entrance and sliding exit door at the back of the facility. LPA observed the sliding door's auditory signal not working properly. LPA further observed the sound of the signal is barely heard in staff's room and in other common areas of the facility, ......continued on 809C Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections (POCs) by plan of corrections due dates and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with Celeste Olivarez and licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.