Incident investigation·September 30, 2022

Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an case management regarding an incident report for R1. LPA met with Jeff Emoruwa, Director of Health Services. During the course of the visit LPA interviewed S1, S2 and S5. LPA collected the following documents: resident roster, physician's report; ID and emergency information, behavior mapping, comprehensive assessment and service plan, care conference sheet, and resident appraisal. LPA requested staff roster, and police report for R1. UIR, records and interviews revealed that R1 eloped, R1 was not a flight or elopement risk. Contractors were on site and the alarm system had been disarmed by S3. S3 asked S2 to close the doors but was not aware that the alarm system had not been armed/reset. S1 stated that S2 is a new employee and the alarm system has two different codes that need to be activated. R1 wandered about two blocks away to a synagogue on Jefferson St and Berkeley police were called by an unknown person. Berkeley Police reported to S5 that R1 appeared confused, was in their custody, and returned R1 to the facility appearing uninjured. S1 completed in-service training with Plant Operations and Care Staff; all staff are responsible for disarming/arming the alarm system themselves and verifying it's operational. No deficiencies cited, exit interview, and a copy of this report provided to Jeff Emoruwa.