complaint·October 24, 2022

Regarding allegation: Resident was illegally evicted. It was alleged that R1, a memory care resident, had a series of incidents where R1 tried to leave the facility unassisted. Due to an increase of incidents, most of them being successful, the resident was sent to the hospital for a psych evaluation to determine if the resident needed a higher level of care. The facility has a secured memory care unit that is under surveillance and staffed with caregivers to oversee the residents. It is not a locked perimeter. During interviews conducted with S1-S7, (7) of (7) staff stated they were notified R1 was discharged from the facility, unknown why. Per interviews with S1-S7 and review of documents obtained, an eviction notice was not issued to R1, otherwise staff would have knowledge. S2 stated that S8 was the interim administrator at the time of the incidents leading to R1 leaving the facility, and was responsible for making the decision of R1 not returning. S3 stated they spoke to R1's responsible party and was told they were seeking new placement for R1 since R1 could not return to the facility, per S8. A reassessment of R1 by the facility was not conducted to receive R1 back, following discharge from the hospital. Therefore, the resident was evicted illegally. This allegation is substantiated. Regarding allegation: Staff failed to prevent resident from AWOL’ing from facility. During interviews conducted with S1-S7, (7) of (7) staff state that R1 fled from the facility on several occasions without assistance. Per R1's Physician's Report, R1 was unable to leave the facility unassisted due to diagnosis of dementia. R1 resided in the facility's memory care unit, which is a secured perimeter, not locked. The perimeter has surveillance cameras and alarm systems when the doors are opened. All staff interviewed have knowledge of the resident being able to open the doors of the secured area and leaving, but did not request a psych evaluation for R1 until 9/13/22 for reassessment of the level of care R1 needed. During an incident occurred on 9/12/22, R1 AWOL'ed (absence without leave) from the facility. Local law enforcement had to be notified and a facility staff found R1 at the shopping center across the street from the facility about 1 hour after the resident went missing. This allegation is substantiated. Based on LPA's observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D. An exit interview was conducted with Administrator Karen Meacham and a copy of the report and appeal rights were provided. Regarding allegation: Facility failed to report incident to CCL and Resident's Family. It was alleged that R1, a memory care resident, had a series of incidents where R1 tried to leave the facility unassisted. Due to an increase of incidents, most of them being successful, the resident was sent to the hospital for a psych evaluation to determine if the resident needed a higher level of care. The facility has a secured memory care unit that is under surveillance and staffed with caregivers to oversee the residents. It is not a locked perimeter. During interviews conducted with S1-S7, (4) of (7) staff stated that the incident was reported to Community Care Licensing (CCL) and to R1's responsible party. Per the incident reports received and reviewed, facility staff did notify CCL and R1's responsible party. During a telephone interview conducted with R1's responsible party prior to the visit to the facility, R1's responsible party stated they were notified of previous incidents, but was not notified of R1 being transferred to a hospital for a psych evaluation until days after the incident occurred; However, they were still notified. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. An exit interview was conducted with Administrator Karen Meacham and a copy of this report was provided.