Incident investigation·June 24, 2022

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA met with Administrator Noel Gutierrez and Romualdo Amante. On 6/7/2022 the Agency (CCL) received a report that Resident 1 (R1) left the facility unassisted on 5/29/2022. R1 left the facility unassisted and was gone 4 to 5 hours. R1 left the facility sometime between 4 and 5pm when visitors left the facility and the door was opened. After the visitors had left staff discovered R1 was not at the facility. Staff could not find R1 and contacted the Administrator and the police. The facility called the police and were informed R1 was at the hospital to be evaluated. The police were contacted by a concerned neighbor that an elderly person appeared to be lost. The police found R1 and took them to the hospital to be checked. The facility contacted the responsible party. The facility Administrator returned R1 to the facility when they were released from the hospital around 9 pm. R1 is at the facility and no further issues reported. The facility does have a front door alarm and is doing regular checks on all the residents. Based on the information gathered through interviews and a review of the incident reports, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided to the Administrator.