Incident investigation·February 5, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Manager Gabriela Zamora. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 02/01/2024). According to the LIC624: on 01/31/2024, Resident #1 (R1) left the facility on foot. [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff followed R1, but were initially unable to redirect R1 back, leading staff to call 911. R1 returned with staff to the facility about an hour later, unharmed. During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were indeed safe and unharmed. LPA tested auditory staff alert devices on the facility’s six exterior exit doors. LPA also collected copies of and reviewed pertinent care records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 02/24/2022), R1 was diagnosed with bipolar disorder. R1 was not diagnosed with Dementia or Mild Cognitive Impairment (MCI). R1’s physician determined that R1 was ambulatory, independent in Activities of Daily Living (ADLs), not confused/disoriented, able to follow instructions, able to communicate needs, and able to leave the facility unassisted. The latest LIC625 Appraisal/Needs and Services Plan (dated 01/13/2022) which Licensee performed on R1 corroborated the above points. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] During today’s visit, R1 declined to be interviewed by LPA. However, staff interview showed R1 had a history of refusing medications which were prescribed by their assigned psychiatrist; this was also true during the time of the incident. On 01/31/2023 around 4:00 AM, R1 was hallucinating and claimed to have seen a man inside their bedroom. R1 became troubled and left the facility on foot via the lobby's front doors. Staff #1 (S1) saw R1 as they exited and followed them, trying unsuccessfully to redirect them back to the facility and calling 911. R1 walked around three blocks to the local fire department’s station, where personnel there helped convince R1 to return to the facility. R1 then walked with S1 back to the facility, under the observation of a sheriff’s deputy who arrived later. R1 was unharmed. During today’s visit, LPA observed (and manager interview confirmed) that the facility’s fire extinguishers had not been serviced within the last twelve (12) months, as was required for Licensee to maintain ongoing compliance with its prior approved Fire Clearance (issued by the local fire authority). Per manager interview: a) The facility’s lobby front desk is not usually staffed between the hours of 10:00 PM and 6:30 AM; and, b) on the date of LPA’s visit, there were around thirty-one (31) residents in care diagnosed with dementia. During today’s visit, LPA observed: For five of six exterior doors, staff alert devices were present and intact, but staff had them turned off (i.e., deactivated) during the daytime. These doors were not continuously visually monitored by staff. Also, one of two sensors associated with the facility’s lobby entrance doors was not working, effectively allowing the front door to be opened from the inside without triggering a staff alert. Licensee had constructive knowledge of the faulty sensor needing repair since mid-August 2023. Based on a review of records and confirmed by manager interview, Licensee did not have a current and signed Admissions Agreement for R1, as was required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Three (3) deficiencies were cited per California Code of Regulations, Title 22 (see the LIC 809-D pages). Since one of the deficiencies was also a violation of the facility’s fire clearance, an immediate civil penalty of $500 was assessed (see the LIC 421-IM page). Plans of Correction was jointly developed with the licensee. LPA also issued Technical Assistance (TA) regarding conducting a reappraisal of R1, and regarding an infection control requirement (see the LIC 9102-TA pages). An exit interview was conducted with Zamora, to whom a copy of this report, the LIC809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.