Incident investigation·August 19, 2025

Licensing Program Analyst (LPA) Fred Arias made an unannounced case management visit to follow-up on an Unusual/ Special Incident Report (SIR) received in our Regional Office on August 13, 2025. LPA was greeted and granted entry by staff and explained the purpose of the visit. Administrator (AD) Deanna Chris Landon arrived shortly to assist with the visit. LPA along with AD toured the facility. LPA observed auditory exit alarms were operational during today's visit. LPA obtained the following for review: Staff schedule for the week of August 3, 2025, Resident Identification and Emergency Information, Physician's Report and Appraisal Information. The Appraisal and Physician's Report do not indicate wondering behaviors for Resident 1 (R1). AD and two staff stated R1 had not exhibited wandering behavior prior or since the incident. AD clarified the incident occurred on August 9, 2025 and not August 11, 2025 as indicated on the incident report. AD stated a meeting has been scheduled with R1's physician and spouse for 08/20/2025 to discuss R1's change of condition. An updated appraisal will be created based on the result of the meeting. AD also stated new exterior cameras will be installed around the facility and an improved locking latch will be installed on the front gate within the week. AD and two staff stated residents are provided with daily activities including exercise, games, and time spent outside. A third party person provides exercise classes on Tuesdays and Thursdays. In-service training has been completed by AD with regards to expedited response to auditory exit alarms. AD stated there has been a discussion with R1's spouse to provide R1 with a wrist Wander Guard with written consent. AD agreed to provide documentation of items discussed by end of day on August 22, 2025 to LPA. Based on the observations, record review and interviews made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted and a copy of the report along with LIC811 was left at the facility.