Incident investigation·June 22, 2021

Licensing Program Analyst (LPA) Angela Elliott and LPA Erik Gonzalez-Campos, conducted a case management follow-up with Paul Oseso, General Manager. Community Care Licensing (CCL) received an incident report on 4/28/2021 for an incident occurring on 4/26/2021 for R1. Around 7:15 PM R1 was noted to be missing. R1's Wanderguard device was attached to their walker. Staff found R1 in an adjacent business' parking lot next door to the facility. A couple from the community was on the phone with the police at the time trying to find R1 help. R1 rode back to the facility at 7:30 PM, was assessed and determined to have no injuries. Paul indicated because the Wanderguard was on R1's walker and the alarm did not sound when they left the facility. Documentation review confirms R1 was not able to leave facility unassisted. There was another incident for R1 that occurred on 5/15/2021. R1 exited the building at 2:45 AM triggering the alarm. The alarm had gone off for a while and was not answered by S1 . R1 had Wanderguard on wrist triggering alarm. R1 was found by S2 at the entrance to the facility with two men who had re-directed R1 to come back into the building. R1 was assessed and determined to have no injuries. S1 was non-responsive during incident and was subsequently terminated. There has been an additional person at the front desk overnight, and R1 has a 1:1 up to 11:00 PM at night which began 5/21/2021. R1 has since moved to the Memory Care portion of the facility on 6/16/2021. 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. Exit interview was conducted with Administrator. Immediate civil penalty for $500.00 was issued for Zero Tolerance , absence of supervision.