complaint·December 10, 2024

The investigation revealed the following: In regards to the allegation: “Staff did not adequately supervise resident in care resulting in resident wandering from the facility.” It is alleged that R1 was wandering into traffic and put herself in harm’s way. Interviews with S1-S2 corroborated the allegation. S1 stated that the incident happened early evening on 09/30/2024. S1 indicated that R1 was admitted to the facility recently. S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. Interviews with W1-W2 also corroborated the allegation. W1 stated that she drove around to help in locating R1 and was handed over to her by the authorities and W1 took R1 back to the facility. W1 indicated that she did not observe injury on R1. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. LPA interviewed R1 but cannot recall the incident. Based on file reviews, resident assessment record indicated that R1 is a wanderer who requires multiple behavioral interventions for redirection including wandering. The physician’s report dated 08/19/2024 indicates that R1 is diagnosed with dementia. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility. Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Laura Sanchez, Health Services Director along with the Appeals Rights.