Incident investigation·September 9, 2021

On 9/9/2021 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 9/1/2021. LPA met with staff, Edna Banagale. Licensee, Gwynne Judan arrived 30 minutes later. Incident report dated 9/1/2021 revealed that R1 was found missing. Before staff notify local law enforcement, police officers was at the front door bring R1 back to the facility. Interview with S2 revealed residents are checked every 2 hours during night shift. When S2 check residents at 4:30AM, all residents were still in their rooms. However, when S2 check residents at 6:30AM, R1 was missing and S2 informed S3 to call the police. S3 spoke with police and was informed that R1 was with police officer. R1 and police officer was at the facility within 10 minutes. S1 stated that the alarm system was defective on the day of the incident and a new alarm system was purchased/installed on the same day of the incident During record review, LPA observed that physician's report dated 4/18/2019 stated that R1 cannot leave the facility unassisted. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty. Exit interview conducted. A copy of this report and appeal rights provided.