Incident investigation·February 12, 2024

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on 2/05/2024. LPA met with Assistant Administrator (AAD) Jae Win Rim and explained the reason for the visit. Incident report indicated that on 2/03/2024 at about 4:00 p.m., direct care staff informed front desk that Resident 1 (R1) was not in the dining area. Staff initiated search for R1. Camera footage was reviewed, and resident was seen leaving the facility at 3:22 p.m. Police were called and R1’s family was notified. Facility staff continued to try to locate R1 and found them at the nearest 4-way intersection. During today’s visit, LPA interviewed AAD who confirmed details of the incident report. LPA was unable to interview R1, as they away at day program. LPA reviewed R1’s Physician Report (LIC602) dated 7/05/23, which indicates R1 has a dementia diagnosis and wandering behavior. LPA also reviewed Resident Appraisal (LIC603) dated 1/27/24, which indicates R1 needs special observation and 24-hour supervision. Based on information gathered, LPA determined that staff did not adequately supervise R1, resulting in elopement from the facility; a Deficiency was cited on today’s date. An exit interview conducted, and a copy of this report and appeal rights was left at the facility.