Incident investigation·June 21, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on incident reports received by Community Care Licensing. LPA was greeted and granted entry into the facility by Executive Director Justine Ortiz and explained the reason for the visit. Incident report dated 06/09/2022 indicated Resident 1 (R1) eloped out of the memory care unit and was found about one mile away by facility staff. Facility investigation revealed the alarm went off at rear gate at approximately 7:40 PM. Staff responded to the alarm and began a head count. It was noted R1 was absent and staff started looking for the resident. Facility contacted the authorities as well. Camera footage indicated the resident went into the courtyard and then out the gate. It is presumed the resident went through the field adjacent to the facility and up onto the road. Resident was discovered by staff by a shopping center and returned to the facility with no adverse effects. Resident was put on half hour checks and family and physician notified. Per physician report dated 04/29/2022, R1 has a diagnosis of Dementia and a history of wandering. LPA spoke with R1 during the visit. R1 appeared happy and well taken care of. Incident report dated 05/31/2022 indicated R2 was found on the floor by staff in the resident's restroom around 12:55 AM. R2 was observed to have a skin tear and became somewhat incoherent. 911 was called and paramedics responded. R2 was transported to Mission hospital and diagnosed with a fractured right hip. R2 had surgery and was transported to a skilled nursing facility. Per physician report dated 05/22/2020, R2 is diagnosed with Mild Cognitive Impairment. Resident was on Hospice due to Senile Degeneration of the brain. Per facility, resident was on two hour checks, had bed rails and a pendant for assistance. Based on the observations and interviews made, 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 with Executive Director.