Incident investigation·November 6, 2024

On 11/06/2024 at 3:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 10/24/24. LPAs met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit. The incident report indicated that R1 eloped Memory Care (MC) unit on 10/19/24 at around 2:00pm. LPAs interviewed S1 and S2 that observed R1 walking down the street. S1 and S2 stated that they were just arriving for their shift before 2pm and noticed someone that looked familiar. S2 stated that they recognized R1 walking across the street towards Sprouts Farmers Market and started running towards them to direct them back to the facility. S1 stated that they informed S3 that R1 had eloped down the street. LPAs interviewed S3 that stated that they got on their radio and informed MC of the eloped resident and the MC care staff came out to look for R1 and direct them back to the facility. LPAs interviewed S4 that stated that R1 walked out the egress door which is located on the east side of the building. S4 stated that the plate was stuck which is why the alarm and lights did not go off. S4 stated that they re-adjusted the Maglock and the door was fixed. LPAs obtained the following documents: physician's report, care plan, memory care staff schedule for 10/19/24 and maintenance work order for 10/18/24. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.