Incident investigation·April 24, 2024

On 04/24/2024 at 2:35 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 01/31/2024. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that Resident (R1) who resides in memory care was seen entering the community through the front lobby at around 10:30 PM. The incident reported indicated that R1 was escorted back to memory care. The incident further reported that the care staff noted that the resident's bedroom window was open and the screen was off. LPA interviewed S1 that stated that the facility installed window stoppers on all windows in memory care and sensors that will register to the front desk staff that's there 24/7. LPA asked S1 where were the memory care staff and S1 stated that the memory care staff checks on the residents but at the particular time they may have been providing care to other residents. S1 stated that this was a 15 minute gap from the last check. LPA toured with S1 the outside perimeter of R1's bedroom window and walked from the location to the front entrance of the lobby. LPA observed that the walk outside was leading to the residential carport area, to the street traffic on Geary Rd. LPA asked S1 are the front door entrance locked which per the report it was around 10:30pm and S1 stated that there is always someone at the front desk. LIC809-C Continued... LIC809- C Continued... LPA observed and with interview that R1 was able to force open the window and remove the window screen from the window. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.