Incident investigation·May 29, 2024

This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on May 23, 2024 regarding an incident involving Resident #1 (R1). LPA met with Administrator (AD) Tammy Joo and discussed the purpose of the inspection. During today’s inspection, LPA toured the facility with AD. LPA conducted health and safety checks on the residents present and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA conducted interviews and requested and reviewed copies of the resident roster, staff roster, and resident files. The investigation into the incident revealed the following: on May 22, 2024, R1 left the facility during the overnight shift without being observed by staff, staff immediately noticed and called police, police found R1 about an hour or less later nearby the facility and took R1 to a hospital, R1 sustained no serious injuries, and R1 was moved out of the facility and relocated to a memory care unit. Per R1’s Physician’s Report, they were not able to leave the facility unassisted. AD stated that R1 had no history of wandering, facility staff had been conducting checks on R1 and other residents regularly, and when R1 left the alarm on the door went off and facility staff, who had recently just seen R1, checked for R1 again and noticed they had left, and the facility acted immediately to notify police and look for R1 within the facility, which resulted in R1 being found very close to the facility, very quickly, and with no injuries. Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.