complaint·April 6, 2022

secure did not report the incident to the Administrator. Administrator stated R1 left the facility between 5:00 am and 7:00 am. Administrator stated had reminded Caregiver (S1) must make sure the exit doors are secure and S1 must also immediately report all incidents to the Administrator. LPA also interviewed the second caregiver (S2) who was working the morning of April 1, 2022. S2 stated had seen R1 at 5:00 am within the facility. S2 stated R2 set off the fire alarm at approximately 5:00 am. S2 did not witness R1 leaving the building but stated probably exited the building between 5:00 am and 7:00 am. Administrator confirmed the R1 returned to the building at 11:00 am. LPA reviewed resident's file and observed the Physician's Report for R1 states the resident is not able to leave the facility unassisted. Based upon LPA's interview of the Administrator and the Caregiver and the resident's Physician Report, the allegation is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.