Incident investigation·December 11, 2023

On this day at around 1:45 pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct a case management-incident visit and met with Administrator Soledad Bacani. LPA explained to Administrator the purpose of the visit. On 12/7/2023, Administrator left vm to LPA regarding Resident 2 (R2) missing from the facility. On 12/11/23, LPA made a follow up with Administrator. Administrator informed LPA that Resident 2 (R2) who had Alzheimer's Disease left the facility on 12/7/23 without staff knowledge. Administrator and staff tried to find R2 but failed. Administrator states she informed R2's family and Union City Police Department. And on 12/10/23, Administrator states R2's husband informed staff 1 (S1) that R2 passed away on 12/8/23. During the visit, LPA obtained the following records for Resident 1 (R1): Medication Administration Record (MAR) Physician's Report Admission Agreement Appraisal Needs and Services Plan Death Report Incident Report The deficiency is cited (refer to Lic 809D) from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview was conducted with Soledad. Appeal Rights was provided.