Incident investigation·September 17, 2024

Licensing Program Analyst (LPA) Angela Barutyan conducted an unannounced case management - incident visit at 10:20AM. The purpose of this visit is to conduct an investigation regarding a self-reported incident that occurred on 09/10/2024. Upon arrival, the LPA met with staff. Administrator Kristina Adamyan arrived at 10:35AM and the reason for the visit was explained. Entrance interview conducted. On 09/11/2024, the Department received an incident report stating that on the early hours of 09/10/2024, Resident 1 (R1) left the facility unassisted, and staff were unaware. Resident 2 (R2) was woken up by the light coming from R1’s room and when R2 went to investigate, R2 found that R1 was not in their room. R2 notified Staff 1 (S1) around 12:30AM who went to investigate and found that the main entrance door was open. S1 looked inside and outside the facility and was unable to find R1. S1 notified Administrator Adamyan who arrived at the facility around 12:45AM and looked all throughout the facility and neighborhood. Around 2AM, Administrator Adamyan contacted nearby hospitals and the LAPD who arrived at the facility. During this time, Administrator Adamyan contacted R1’s family who arrived at the facility to continue the search. According to the report, R1 was found around 03:45AM and paramedics were promptly called to assess R1’s vitals. R1 was found to be dehydrated and was transferred to the hospital to receive fluids. R1 was discharged from the hospital around 11AM to the facility. During today’s visit, LPA Barutyan conducted a brief physical plant tour at 10:22AM to ensure there are no health and safety hazards, conducted interviews with the Administrator, two (2) staff members, one (1) resident, and one (1) family member between 10:35AM-12:00PM, and conducted a file review. LPA requested and obtained copies of pertinent documents relevant to the investigation via email on 09/11/2024. Report Continued on LIC 809-C Record review of R1’s physician’s report dated 03/01/2023 indicates that R1 has dementia and is unable to leave the facility unassisted. R1 does not have an updated physician’s report for the current year. Record review of R1's appraisal of needs and services dated 03/15/2022 revealed that R1 requires assistance and guidance in their care plan. R1 does not have an updated reappraisal of needs and services. Interviews conducted with staff revealed that R1 is not able to ambulate and staff believe R1 was unlikely to have left the facility without some kind of assistance. LPA was informed that S1 found R1 three (3) hours after the search began in the backseat of R2’s vehicle. Staff stated that S1 did not hear the resident leave because R2 turned off the exit alarm and S1 was in the garage doing laundry. Interview conducted with the Administrator revealed that S1 put residents to bed at 09:30PM. R1 woke up at 11:15PM and was hungry. R2 was also awake and together they went to the kitchen and asked S1 for food. After eating, S1 put R1 to bed and within forty (40) minutes at 12:30AM, R2 notified S1 that R1 was missing and left the facility. S1 found that the front door was open and began the search while also contacting the Administrator. Administrator stated that R2 has a tendency to turn off the exit alarm and S1 does rounds every two (2) hours to check on the residents, which is why R1 was able to leave without notice because S1 had just done a round forty (40) minutes prior. Administrator contacted the family, the LAPD, and nearby hospitals around 2AM. Administrator stated that R1 was eventually found by S1 at 03:30AM in the backseat of R2’s car of which the door was left ajar. According to staff and Administrator, R1 was missing from 12:30AM-03:30AM. Administrator stated that R1 was unlikely to have left on their own because R1’s cane was left behind in their room and R1 is unable to ambulate more than ten (10) feet without it. The driveway was also poorly lit and R1 needs assistance to sit down. Administrator stated it is unclear how R1 could have sat in the car on their own. During the visit, LPA interviewed R1 who was confused and unable to recall any incidents besides going to the hospital last week for an unknown reason. Furthermore, during an interview with R1’s family member, family member stated that the Administrator contacted them at 03:30AM, three (3) hours after R1 was found to be missing. Family arrived at 4AM and R1 was found at 04:30AM, meaning that R1 was missing for a total of four (4) hours. The interview also revealed that family was informed S1 was asleep when R2 notified that R1 was missing. Report Continued on LIC 809-C During the physical plant tour at 10:23AM, LPA observed the auditory exit alarm to R1’s room was turned off. Staff turned on the alarm during the visit and was functional and operating. During LPA’s interview with R1’s family, it was revealed that they have never heard the auditory exit alarm or observed the light on the device to be on. According to the family, they were not aware that one was installed as the device has been kept off and were only informed that there was a device when the LPA asked staff to turn on the alarm while family was visiting. Staff interviews revealed that the auditory device had just recently been turned off earlier in the day because the sliding exit door was opened to let a breeze in. Staff and Administrator were informed that the devices need to be on at all times. At 10:25AM, LPA observed the auditory exit alarm in the family room was turned off. Staff turned on the alarm during the visit and was functional and operating. At 10:26AM, LPA observed the living room to be missing an auditory exit alarm. Upon further inspection, LPA observed an uninstalled auditory exit device on the piano in the living room at 10:30AM. Administrator was unable to remain at the facility for the delivery report. LPA delivered report to caregiver Ana Gutierrez who signed in the Administrator's place. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.