Incident investigation·August 2, 2024

On 08/02/2024 at 10:15 AM Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/17/2024. LPA met with Executive Director, Marissa Espinoza and explained the purpose of the visit. The Incident report stated that at approximately 9:20 PM, R1 was found outside the community lying face down in a bush. LPA interviewed S1 and S2 for further details. S1 stated that the Wander Guard alert went off and the alarm was heard. S1 stated that S3 went to R1's apartment to check if they were in their room and they observed that they were gone. S1 stated that S3 and S4 went outside looking and they observed R1 laying in a bush face down located in the front entrance of the facility. S1 stated that this occurred between 9-10 PM during shift change. S1 stated that R1 had no injuries. S1 stated that the facility increased their safety checks for R1 throughout the night. S1 stated that there was a care conference with S1, S2 and R1's responsible party. S1 stated that they started "16 Checks" for R1. S1 stated that R1 moved to the memory care unit on 07/31/2024 which would provide oversight and simulation for R1. LIC809-C Continued... LIC809-C Continued... LPA obtained a copy of R1's Physician's Report, Needs and Services Plan, Resident Assessment and Care Staff Schedule for 06/09/2024. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.