Follow-up on corrections·February 27, 2025

On 2/27/25 Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina, conducted an unannounced CASE MANAGEMENT visit at this facility to issue deficiency in conjunction with complaint control # 31-AS-20241106150126. LPAs met with facility Executive Director (ED) and explained the reason for the visit. LPAs conducted a physical plant walk through, at approximately 9:20am, to ensure that the facility is in compliance under Title 22 California Code of Regulations. At 9:50am, LPAs requested staff and resident rosters. During the initial complaint visit on 11/7/2024, LPA Khurshudyan conducted interviews and records review and informed that on 11/3/2024 around 1:30am R1 attempted to awol from the Memory Care unit and tried to exit the egress door to Assisted Living area. S1 and S2 (nights shift caregiver and MedTech) attempted to redirect R1 back to Memory Care unit, however, R1 got aggressive and while kicking S1’s left knee lost their balance and hit their face on the door. First aid was provided right away and with the help of S1 and S2 R1 went to their room. The following day on 11/4/2024 around midnight R1 had another episode of aggressive behavior and another attempt to awol from the Memory Care unit. Despite several attempts of redirecting R1 to their room, R1 opened the back exit egress door and was able to go outside and fell on the concrete. LPA conducted tour and observed that the egress door did properly work, however, when the alarm went off the facility did not have sufficient night shift caregivers on the floor to prevent the incident happening. R1 was transported to the hospital for further evaluation. Lastly, LPAs were informed that the Memory Care Unit had total of fifty-five (55) residents, two (2) of which had wandering behaviors. Also, two (2) staff members were scheduled for the night shift to cover 1 st and 2 nd floors by providing care and supervision. During interviews ED and Memory Care director confirmed that R1 had wondering behavior and numerous episodes of incidents got recorded of R1 being agitated towards staff and other residents in care and the incident happened due to failing to respond to egress door alarm in a timely manner. Deficiencies are cited and noted on LIC 809D. Exit interview conducted. Appeal rights explained. Copy of this report signed and delivered.