Incident investigation·September 1, 2023

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 8/28/23. LPA met with Maria Quizon and explained the reason for the visit. On 8/28/23 the department received an incident report which noted resident #1(R1) was not found during a morning check at 6:45am on 8/27/23. R1 was found at 8:00am in another residents room. Per administrator the procedure the staff should follow when a resident cannot be found in the facility is to contact family, search for the resident, and call the police to do a report if the resident is not found after checking all the rooms. Facility did not contact Local Police Department as resident was found at 8:00am. Documents reviewed revealed R1 has dementia noted in physician's report dated: 5/18/22 and notes R1 cannot leave the the facility unassisted, manage own cash resources, and/or handle own medication. Per administrator R1 resides in the assisted living portion and not in the dementia unit. R1 gets checked in the morning before breakfast and before the end of the afternoon shift. LPA interviewed R1 and staff during this visit. Per Title 22 Regulations facilities serving residents with dementia must follow dementia care regulations. Therefore, deficiencies are noted on LIC809D. Exit interview was conducted with Maria Quizon and a copy of this report was provided.