Incident investigation·August 1, 2024

On 08/01/2024 at 11:15 AM, Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 06/14/2024. LPA met with Executive Director (ED), Brittany Karlinski and explained the purpose of the visit. The incident report received stated that Resident (R1) eloped from the side exit door of the memory care unit at around 8:15 AM on 06/14/2024. The incident report indicate that another Resident (R2) observed R1 walking out the back door and that the staff located R1 outside across the street. LPA interviewed Staff (S1) that stated there were 3 (three) memory care caregivers and 1 (one) Med Tech scheduled during that time. S1 stated that R1 exit the side door which is located on the east side of the facility building. S1 stated that the alarms went off when the door was breached and that R2 went to staff to inform. S1 stated that the caregivers were on the opposite side of the area where R1 eloped and were currently occupied with breakfast and other tasks with other residents in memory care. S1 stated that after R2 informed the staff, the staff immediately went outside and found R1 standing outside across the street. S1 stated that staff brought R1 back to the facility and that R1's responsible party was notified. S1 stated they had a care meeting with the family and suggested that R1 be placed on a 1:1 assistant. S1 stated that R1 was placed on a 1:1 assist on 06/14/2024 from 7AM to 7PM daily. LIC809-C Continued... LIC809-C Continued.... LPA obtained a copy of resident's (R1) Physician's Report, Staff Schedule for 06/14/2024, Staff Schedule (06/10/24, 06/16/24), R1's Preplacement Appraisal (03/28/24), Resident Assessment (05/26/24, 06/28/24), Needs and Services Plans (05/31/24, 07/08/24), Physician's Orders (08/01/24), Service Plan (07/09/24), Health and Safety Assessment (07/09/24) and copies of Wander Management System and Elopements (12/01/23) policies. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report was provided to ED.