Incident investigation·August 12, 2021

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct another case management as follow-up to the case management conducted on December 15, 2020. LPA requested for copies of LIC601 Identification and Emergency Notification, Physician's Report, Pre-placement Appraisal, Appraisal/.Needs and Services Plan, staff schedule. On December 12, 2020, R1 was found not in his room when staff brought him lunch. Staff searched the dining room and common areas but unable to find him. Staff reported to Wellness Director (WD). Further search done but unsuccessful. Responsible person, executive director and associate director were informed. WD was about to call the police when R1 returned with police escort. Review of resident’s (R1) LIC602A Physician’s Report revealed R1 is confused/disoriented, has wandering and sundowning behaviors and can not leave the facility unassisted. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12 month period may result in civil penalties. Deficiency and plan and proof of correction were discussed with Apolinario 'Paul' Gozon. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.