Incident investigation·November 18, 2022

Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on an incident report submitted to the department on 8/12/22. LPA Flores met with Jeanine Hernandez Assistant Administrator and explained the reason for the visit. On 8/12/22 LPA Flores received an incident report (SIR) regarding Resident #1(R1) found by Pasadena Police Department 3 blocks away from the facility. On 8/26/22 LPA Flores requested facility to submit to the department physician's report, admission agreement, needs and service care plan, medication sheet, and face sheet. On 11/16/22 LPA Flores contacted administrator to request the documents listed to be submitted to the department. On 11/18/22 LPA Flores reviewed the documents faxed to the department. Per physician's report reviewed R1 is not allowed to leave the facility unattended and notes wandering behavior. R1 was admitted to the facility on 8/9/22. R1's physician's report notes R1's secondary diagnose is Alzheimer's and has mild cognitive impairment. Preplacement assessment notes R1 wandering behaviors. On 11/18/22 LPA interviewed assistant administrator, staff #2(S2), R1 and representative of R1. LPA observed 3 exit points, main entrance has a lock door and a concierge is in the lobby to allow entry and exit. Exit door near the laundry exits to passage way to egress exit Laundry door gate/west exit which has the 15 seconds hold and the sound device has been quite due to neighbors concerns. The egress system notifies the front desk and front desk staff notified on radio. North gate has egress system and alarm was set off once assistant administrator open the gate. North Gate exits to the street to the right of the main entrance. North Gate was used by R1 to exit facility. Interview with Assistant Administrator revealed R1 left the facility before 4:00pm and was brought back by police department at 4:30pm. Facility provided a copy of S2 Performance Improvement Notice dated 8/15/22. Facility is currently providing hourly checks for R1. Deficiencies have been noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Jeanine Hernandez Assistant Administrator and a copy of this report, LIC 809D, and appeal rights were provided.