Incident investigation·April 28, 2021

On 04/28/2021 at 10:00 AM Licensing Program Analyst (LPA) McCrory conducted an unannounced visit to conduct an Investigation/ Case Management visit regarding an incident that occurred at the facility on 04/16/2021. Prior to visit, LPA conducted a self-assessment and had no COVID-19 related symptoms. During visit, LPA wore a mask for COVID-19 precautionary measures. Upon arrival, LPA met with Tatiana Danu, Administrator. LPA reviewed the following documentation at the facility: Needs and Services Plan, Hospital Discharge paperwork, Staff Training, Personnel Report (LIC 500), Resident/Client File(s). According to self reported incident report provided by the facility to the Department, on 04/16/2021 Resident (R1) left facility grounds unassisted. It is notated that R1 has a diagnosis of Alzheimer and based on medical assessment is unable to leave the facility unassisted. According to interviews, once staff realized R1 was missing from the facility at 7:49 AM staff searched backyard and nearby streets but could not locate R1 . Facility contacted local law enforcement to report R1’s elopement. At 8:20 AM, local law enforcement reported to the facility. R1 was found by a pedestrian l ying on the ground approximately 1.4 miles away from the facility. R1 appeared to be injured and the pedestrian called the ambulance. R1 was transported to a local hospital where R1 was treated for a head injury with l acerations that required sutures. Law enforcement was contacted regarding R1's location at the hospital and then the facility was notified of R1’s whereabouts. Based on the investigation findings, the facility did not provide proper care and supervision to R1 resulting in R1 eloping from the facility and sustaining injuries. Deficiencies are being cited today from CCR §87468.2(a)(4) and listed on the attached LIC809D. In addition, an immediate civil penalty is being assessed today in the amount of $500 (five hundred dollars). Civil penalties for violations resulting in serious bodily injury is/are pending a departmental review at this time and additional administrative actions may occur.