Incident investigation·July 29, 2024

On 07/29/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a case management visit. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. LPA met with Administrator, Margaret Gardea-Benavidas. The purpose of today's visit is to follow up on an incident that was reported to the Fresno CCL office. It was reported that on 04/18/2024, R1 "wandered out of R1's room" and was returned to the facility by individuals residing in a neighboring home. Interviews conducted and records reviewed revealed that R1 exited out of the side door in R1's bedroom. The facility was in the process of updating the alarm system for the facility, and the caregiver on duty did not hear an alarm. A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Margaret Gardea-Benavidas, whose signature on this form confirms receipt of this document.