Incident investigation·February 15, 2024

At approximately 1:50PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that was received by CCL on 01/17/2024 and occurred on 01/16/2024. LPA met with Administrator, Mary Schramm, and discussed the purpose of the visit. Incident report states that Resident 1 (R1) went out the facilities front door at 10:57AM, and the front desk clerk let the Medication Technician know that R1 was leaving. Staff proceeded to search for him but were unsuccessful, so after 20 minutes of searching they called the police for assistance. R1 was eventually located by a Community Service Officer in the the locked Yacht Club at 12:14PM and was then brought back to the facility. Resident had no injuries. Per conversation with Administrator, R1 is ambulatory and moves quickly. R1's Physicians Report states that R1 has a Dementia DX. Physicians Report has conflicting information, with one section indicating that R1 is not at risk if allowed to leave the facility unsupervised, and another section indicating that R1 is at risk if allowed to leave the facility unsupervised. Review of R1's care plan dated 11/03/2023, indicated that it is required that R1 wears a wanderguard at all times. R1 was placed on frequent 2 hour status checks. It was noted in R1s care plan that R1 is unable to leave the facility unassisted. 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. Exit interview conducted. Copy of report, LIC809D, and appeal rights discussed and provided to Administrator. Signature on form confirms receipt of documents.