Incident investigation·December 14, 2022

Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez made an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPAs were greeted and granted entry into the facility by Executive Director Foudil Manadi and explained the reason for the visit. Incident report dated 11/17/2022 indicated Resident 1 (R) pushed the delayed egress button and exited into the parking lot. Memory Care Director was in the parking lot and observed the resident. Resident was redirected and assessed to have no injuries. Incident report dated 12/02/2022 indicated R1 had exited through the back gate and alarm sounded. R1 was observed by another resident out walking. Resident brought R1 back to the Assisted Living lobby. R1 was assessed to have no injuries. Facility was not notified of incident until 12/08/2022 by staff. During the visit, LPAs toured the memory care and spoke with R1. R1 appears happy and well taken care of. Per physician report dated 07/22/2022, R1 is diagnosed with Dementia with wandering tendencies. Facility is doing weekly elopement drills as well as additional activities to keep the resident engaged. 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.