Incident investigation·May 5, 2022

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on an incident report received by Community Care Licensing (CCL) on 05/03/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit. Executive Director Eric Medor was present during the visit. Incident report dated 05/03/2022 indicated R1 was observed by staff outside the facility approximately .3 miles down the street. Resident was escorted back to the facility and was assessed to have no injuries. Administrator indicates resident was observed by staff walking down the hall inside facility and stated to the staff that the resident was going to an appointment. Staff advised the resident that there was not an appointment and R1 stated the resident would return to the resident's room. Staff continued on with tasks. Five to ten minutes later the staff realized the resident had not returned to the room. Facility staff started looking for resident inside and outside the facility. At this time facility driver observed the resident up the street. Administrator indicates there were no staff at the front desk when the resident left as front desk staff do not come on shift until 8 AM. Administrator exploring options for earlier staff at front desk and resident was outfitted with a wander guard on resident's person and walker. Resident was been at the facility since January 2022. Physician report dated 01/28/2022 indicates R1 is unable to leave the facility unassisted. LPA met with R1 during the visit. Resident appears clean and well taken care. Resident verbalized feeling safe at the facility. Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.