Routine inspection·September 26, 2023

At approximately 10:15AM, Licensing Program Analysts (LPAs) Felias and Rummonds arrived unannounced to conduct a 1 Year Required Visit, and met with Executive Director/Administrator, Shannon Brown. Facility provides care and assistance to Older Adults in Assisted Living and Memory Care. Facility has a plan of operation for dementia care and programming on file. Upon arrival, LPAs were informed that there were 34 residents in Assisted Living and Memory Care with 37 Independent Living residents for a total of 71 residents in care. LPAs were also informed that there were 21 staff members on-site. At approximately 10:30AM, LPAs reviewed the Facility's Staff Roster with Administrator and found that all staff members on site were background cleared and associated to the facility per regulation. At approximately 11:00AM, LPAs conducted a walk-though of the facility with Administrator and observed the following: Facility consists of multiple buildings for Assisted Living and Memory Care. Facility has an Extended Care unit which is a separate wing for Older Adults that require a higher level of care. Facility also has independent living units on the property. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a infection control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for a sample size of 8 sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguishers were last inspected January 2023. Facility smoke detectors are hard wired and connect directly to the local fire station. Facility's smoke and carbon monoxide detectors and sprinkler system were last inspected November 2022 and January 2023. Facility's last fire drill was conducted on July 2023. At approximately 12:45PM, LPAs reviewed a sample size of 3 resident files. Resident Files were all found to be well organized, thorough and contained the required documentation. Continued on LIC809C Continued from LIC809 LPAs also followed up on a self-reported incident that was submitted to Community Care Licensing (CCL). incident Report 1: On 9/13/2023, CCL was verbally informed that the facility was searching for Resident 1 (R1) who had disappeared during a community outing to the local zoo. CCL received an update that evening stating that R1 had been located and was safe. Facility submitted an incident report on 09/15/2023 regarding the incident and made all appropriate notifications per regulation. LPAs discussed R1 with Executive Director, and reviewed documents. Per conversation with Executive Director, R1 was apart of a community outing to the zoo that consisted of 3 staff members and 5 residents. At approximately 12:30PM, facility staff took R1 and 3 other residents to the bathroom. Facility staff then provided the residents with lunch. At approximately 1:30PM, facility staff observed that R1 was no longer with the group when they were boarding the bus. Facility staff contacted zoo personnel and police to review security footage. Facility staff and police observed that R1 exited the zoo premises at approximately 12:45PM. At approximately 3:00PM, facility staff notified Executive Director and Health and Wellness Director of the situation who headed to the zoo's location to assist in the search. At approximately 7:45PM, R1 was found safe and unharmed in a nearby neighborhood. Since returning to the facility, R1 has been observed to be at their baseline. Facility conducted an inservice training reviewing dementia elopements and AWOLs. Facility has also implemented new procedures regarding community outings. Per review of R1's Physician's Report, they are unable to leave the facility unassisted or without staff supervision (This deficiency has been cited, see LIC809D, Regulation 87705(b)(2). Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Facility provided LPAs with In-service training materials and documentation. Deficiency cited today for Regulation 87705(b)(2) has been cleared during today's visit. **An informal meeting has been scheduled for October 18th, 2023, between the Facility and the Department. LPAs unable to complete Annual visit. Annual Continuation visit to be conducted at a later date. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.