Incident investigation·November 29, 2022

Licensing Program Analyst(s) Mary Flores conducted a case management visit to follow up on an incident report send to the department on 11/4/22. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason for the reason. On 11/4/22 LPA Flores reviewed incident report regarding Resident #1(R1). Incident report notes that on 10/31/22 R1 was not found in her room at around 7:30pm. Caregiver made facility administration aware and upon checking facility's cameras it was discovered R1 had left the facility around 6:00pm when a delivery driver opened the door. Last caregiver check on 10/31/22 was conducted at 5:26pm and R1 was seen then. Facility contacted Pasadena Police Department(PPD) and (2) two staff went out looking for R1. During the course of the report intake with PPD they were notify that R1 was found. Pasadena Police department officer returned with R1 at 9:52pm. On 11/29/22 LPA Flores conducted a file review of R1's personal file at the facility. The following was observed: Physician's Report dated 7/6/22 notes R1's primary diagnosis is Dementia and notes R1 has wandering behavior and is not able to leave the facility unassisted. Face Sheet notes R1's date of admission was 2/15/21. R1 is under conservatorship, appointed person is to make person and estate decisions for R1. During the visit LPA was notified that a second incident happened on 11/27/22 a copy of the internal incident report was provided to LPA which notes R1 left the facility unassisted on 11/27/22 at 11:30am after a family entered the facility, staff noticed she was no longer in the lobby's sofa and went to look for R1. R1 returned to the facility at 1:20pm. On 11/29/22 LPA Flores was allowed entry to the facility through the main door after ringing the bell, door did not lock behind LPA. LPA observed one receptionist was on a phone call and there were around 7 residents in the lobby, LPA followed to check the door to see if it locked, door continue to be unlocked and after LPA's attempt, receptionist followed to lock the door. Per Assistant administrator staff have to flip switch for door to lock after an entry to lock the door. (CONTINUED ON LIC 809C) LPA reviewed facility's video on 11/27/22 at 11:19:03am two visitors enter the facility the door closes behind them and at 11:19:26am R1 opens the door and exits the building. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report, LIC 809D, and appeal rights were provided.