Incident investigation·August 8, 2022

Licensing Program Analyst(LPA) Michelle Reed arrived at the facility to conduct a case management visit. The visit was conducted to discuss an Unusual Incident that was reported to Licensing on 8/4/22. Upon arrival, LPA met Business Office Manager Leo Serna. Administrator Jennifer Kornmann arrived at approximately 9:30am. On 8/4/22 at approximately 2:50pm, Resident #1(R1's) exited the side door of the Memory Care Unit. Staff was unaware that she had exited. Staff were alerted by R1's responsible party when he arrived to take R1 to a medical appointment a little after 3pm. Upon notice, staff immediately began a search of the property and surrounding area. R1 was found at approximately 3:20pm by the Culinary Food Service Director. R1 was found 6 blocks away from the facility at Newport Ave and Foothill Blvd. R1 did not have any injuries and was taken to her medical appointment by her responsible party. This is not the first time R1 has left the facility, there have been 2 other elopements. The first was on 3/27/22 and the second on 7/24/22. All three elopements involved the delayed egress doors. During the second elopement R1 did not leave the property and was found outside by staff in the parking lot, According to Ms. Kornmann, there is a little bit of a delay for the doors to lock once the key pad is set. Camera's present did show R1 exiting the doors during the delay. Staff have been trained and reminded to ensure that the doors are secure before they walk away. There are also signs at the doors to remind staff to check the doors. At the time of this visit, LPA toured the Clearbrook Building (Memory Care). Delayed egress doors were operating and R1 was observed with a 1:1 care staff. Interviews were also conducted and records reviewed for R1. See LIC809D for cited deficiencies. An exit interview was conducted with Administrator Jennifer Kornmann and a copy of this report and appeal rights were provided.