Incident investigation·April 21, 2022

At approximately 10:15 a.m. on 04/21/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and later Administrator and disclosed the reason for the visit. On 04/18/2022, the facility submitted an incident report regarding Resident #1 (R1). It was reported that at 2:55 a.m. on 04/17/2022, West Hills Hospital notified the facility that R1 was seen unsupervised outside of the facility. R1 was held at the hospital for observation until 04/18. At the time of the incident, facility staff was tending to other residents and did not any hear auditory devices. A power outage occurred on 04/15/22 which may have caused the alarms to malfunction. At 10:25 a.m. staff and LPA tested auditory devices. LPA heard 5 out of 5 auditory alarms on and functioning at the front door, laundry room, family room, hall door, and Bedroom 7 door where R1 stayed. Staff held a conversation with R1. R1 was safe and in good health. At approximately 10:35 a.m. Administrator confirmed that the facility currently serves residents with Dementia. Administrator also attributed the AWOL to the power outage on 04/15. During today's inspection, the facility is in compliance with Title 22 regulations. Deficiency issued for auditory devices turned off on 04/17 on the attached LIC 809-D page. Exit interview conducted. Copy of report provided. Appeal rights provided. Citation issued.