Incident investigation·June 18, 2025

On 06/18/2025 at 2:50 PM, Licensing Program Analyst (LPA) P.Manalo conducted an unannounced Case Management visit regarding a self-reported incident that occured on 06/06/2025. Administrator self-reported the incident on 06/06/2025. LPA met with Executive Director, Emily Poon and explained the purpose of the visit. LPA received a self-reported incident report from the facility that indicated that Resident 1 (R1) went AWOL by exiting through the front door. The facility notified the police, and R1 was escorted back by the police couple hours later. Interview with Staff 1 (S1) and Staff 2 (S2) revealed that R1 was wandering around the hallways in the facility and exited through the front door. When night staff went to check outside, staff did not see the resident. S1 and S2 stated that after the incident occured, R1 began wearing a Wanderguard Bracelet, have safety checks, and have the AUGi system installed in their room. During record review, LPA observed R1's physician report dated 02/18/2025 indicating R1 needs to have supervision when leaving the facility. LPA also reviewed the facility's training on Use of Wanderguard, Elopement Protocol, and Redirecting dated 06/07/2025 and R1's Care Plan. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty. Exit interview conducted. Appeal Rights and a copy of this report provided.