Incident investigation·December 27, 2023

At approximately 1:20PM, Licensing Program Analyst (LPA) Helena Rummonds and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced and met with Executive Director (ED), Liza Hix and Health Service Director, Kimari Pinkney to conduct a Case Management on Incident Report received by Community Care Licensing (CCL) on 11/27/2023. Incident Report states that Resident was found wandering outside of facility grounds by local law enforcement at approximately 10PM. Based on conversation with ED and review of documents, Resident has a dementia diagnosis and is unable to exit facility unassisted. Resident has a history of exit seeking behavior. Resident returned to the community the same night. It is not clear why staff did not respond to the auditory device. Facility has since conducted staff retraining, placed a wanderguard/ alert device on resident, has increased supervision and resident has a 1:1 companion. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.