Incident investigation·October 30, 2023

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 10/25/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Carrie Galloway and discussed the purpose of the inspection. The incident report states the following: On 10/20/23, R1 left the facility to go on a walk, walked for about a mile, sat down on a bench, was offered a ride and returned to the facility by a local member of the community, and sustained no injuries. During today’s inspection, LPA conducted a health and safety check on R1 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, the electricity and water were running, the facility had soap and paper towels, and the medications and sharps were properly stored. LPA confirmed placement of door alarms in the memory care unit. LPA interviewed AD and requested and reviewed copies of the resident roster, staff roster, and R1’s resident file. The investigation into the incident revealed the following: Per R1’s Physician’s Report dated 06/16/23, R1 does not have dementia but is not able to leave the facility unassisted. Per AD, at the time of the incident, R1 resided in the assisted living section of the facility. However, after the incident, R1 obtained a new Physician’s Report dated 10/26/23 which states R1 does have dementia and is not able to leave the facility unassisted. R1 now resides in the memory care unit. CONTINUED. Per AD, R1 left the facility through the front door stating they were going for a walk and this was not unusual because R1 is part of a walking club. After the incident, the facility added motion alarms on the front entryway, created an updated list of residents who are unable to leave the facility unassisted for staff to be aware, and conducted training for front door staff on residents leaving without assistance. LPA confirmed all these items during the inspection. 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.