complaint·June 16, 2023

CONTINUED FROM FORM LIC9099-A The three outside exit gates were all confirmed to be functioning properly. The two outside gates accessible to residents are kept locked. A third gate only accessible by going through a delayed egress door (and triggering an alarm) is unlocked as a fire exit. It was suggested during the visit that resident R1 may have exited the facility through an unlocked sliding window for a unit outside memory care that leads into the locked outside area. Therefore the allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did occur. An exit interview was conducted and a copy of this report was provided to a facility representative. CONTINUED ON FORM LIC9099 After receiving the missing person report, law enforcement conducted a search for the missing resident. Facility staff S1 was informed by a relation of the whereabouts of resident R1 approximately one hour later. Resident was found at a nearby gas station and brought back to the facility. Local law enforcement was notified that resident was no longer missing at this time. Facility administrator stated to LPA Haddad that she had not reported the elopement to the Department because R1 was found so quickly and claimed to not have been aware of the reporting requirements. Administrator however reported the elopement and its resolution to law enforcement and to R1's responsible party. Based on the interview conducted, the allegation is deemed Substantiated, meaning that the preponderance of evidence standard has been met. A Type A citation is issued on the attached form LIC9099-D and civil penalty is assessed per Title 22 regulations. Regarding the allegation that Facility floor is in disrepair, the following has been concluded: During the tour of the physical plant conducted during the initial investigation visit, LPA Haddad observed brand new hardwood floor in the memory care unit. Visual inspection shows the floor is recently installed, however due to a probable installation error, the material bunches up in places and creases up, thus creating a fall hazard. A Type B citation is issued on the attached form LIC9099-D. The floor defects are confirmed to have been corrected since the initial visit, therefore the deficiency is cleared. An exit interview was conducted and a copy of this report along with appeal rights was made and provided to a facility representative.