Incident investigation·February 20, 2024

Licensing Program Analyst (LPA) Ruth Martinez made an unannounced case management inspection to follow-up on an incident report received by Community Care Licensing on February 6, 2024. LPA spoke to Yairell Garcia, Wellness Director and explained the reason for the visit. Incident report indicated that on January 26, 2024, at about 6:00pm, staff on shift were notified by residents sitting out front of the facility that resident (R1) had left the community. The wander guard system alarm did not notify staff that resident had left the community. Staff checked the community and surrounding areas. R1’s wife and 911 was called to make a report. At 6:30pm R1 was located by Administrator and Wellness Director, R1 was making their way back to the community and resident indicated they just went for a walk. Staff evaluated R1 and observed no medical treatment was necessary and had no injuries. During today’s visit LPA spoke to Wellness Director who confirmed details of the incident reported. LPA observed resident throughout the facility and observed residents in the front of the facility as well. LPA reviewed R1’s records and observed physicians report indicates R1 is able to leave the facility unassisted. R1’s primary diagnosis hemipelagic and hemiparesis following cerebral infarction affecting right dominant side, secondary diagnosis is hearing loss, depression, psychosis, seizures and insomnia. Physicians report does indicate dementia however it is not a primary or secondary diagnosis. Due to this reason facility as a safety precaution has a wander guard on R1, physicians report/resident appraisal/care plan do not indicate that R1 has wandering behavior. Facility staff immediately took the following measures facility checked resident wander guard and it was functioning, however facility still changed the wander guard for a new one and had an Inservice training provide to all facility staff. Even though R1 was able to leave the facility unassisted, facility took the appropriate measure because R1 did not check out of the facility prior to leaving. Resident remains at the facility safe, and no further incidents or issues reported. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations . This report was reviewed with the facility representative and a copy of this report was provided to the facility.