Follow-up·June 20, 2022

On 06/20/2022 at 10:00 AM, Licensing Program Analyst (LPA) L Holmes arrived unannounced to conduct a Case Management visit in response to an Unusual Incident/ Injury Report (UIR) for Resident #1 (R1) submitted by the facility to Community Care Licensing Department (CCLD). After arrival at 10:05 AM, LPA saw two residents sitting in chairs outside at the front door and two residents seating inside at the entry of the facility. No staff was present when LPA arrived. LPA called the facility's telephone number and the Medication/Floor Supervisor, Jiena Guien arrived from the back of the facility stating that she was assisting a resident. LPA explained the purpose of the visit and asked if the Administrator (ADM), Norma Tejerao was present; ADM called in sick today, but Jiena said she'd be available to assist. The UIR received 06/17/2022 indicated R1 AWOLed on June 13, 2022. On 06/12/2022, R1 was spotted with a wheelchair near the bus stop on Jiena's day off as he/she drove by San Pablo Ave. in Richmond, CA. R1 was instructed to return to the facility; he/she appeared to be sleeping, it was hot that day and he/she had on a long sleeved black jacket. Witness #1 (W1) stated that the paramedics were called by a bystander and the police were called by the facility. R1 was taken to John Muir Hospital in Concord, CA, discharged and returned to the facility on 06/13/2022. LPA discussed the circumstances of the R1's history at the facility, AWOL, and behaviors including but not limited to self injurious actions with the ADM, S1, S2, and W1. LPA reviewed R1's Admission Agreement, House Rules, Identification and Emergency Information (LIC601), Consent for Emergency Care, Preplacement Appraisal Information (LIC603) dated 04/05/2021, Personal Rights (LIC613C) no date, Physician's Report 03/07/2022, Weight Record 05/20/2021 and Medication Administration Record (MAR) 06/2022. After interviews, R1 does leave the facility unassisted. continued on 809C... ...continued from 809 After reviewing R1's facility records, file and conducting interviews, LPA observed the following: Physician's Report dated 03/07/2022 states mild cognitive impairment and no reappraisal has been completed. LIC601 is incomplete, unsigned and inaccurate. Personal Rights (LIC613C) is not dated, last Weight Record dated 05/20/2021 and has not been updated. LIC603 states dietary limitations include a mechanical soft diet; S1 and S2 are not aware and have not been given any dietary information or orders for R1; S1 and S2 only has dietary information for R2. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Deficiency, plan and proof of corrections were discussed with Jiena. Exit interview conducted, Appeal Rights, and a copy of this report provided to Medication/Floor Supervisor, Jiena Guien.