Incident investigation·October 19, 2022

Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/19/22 to conduct a case management to follow up on a recent AWOL at the facility. LPM and LPA met with facility Administrator Rebecca Thomas and explained the purpose of the visit. LPM and LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical masks. LPM and LPA were screened upon entry by staff. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 09/27/2022 regarding resident (R1) leaving the facility unattended on 09/22/22, at approximately 8:45 pm. Facility staff (S1) found R1 missing from facility while doing facility rounds on 09/22/22 around 8:45pm. S1 searched entire facility including backyard but did not locate R1 and notified administrator and sheriff. Facility staff and sheriff did through search in the area to look for R1 and sheriff found R1 sitting at neighbor house. 9-1-1 was called after R1 was found and R1 was transferred to local Hospital for further evaluation. R1 was evaluated in ER and treated for scrap on R1s right knee. R1 returned from hospital on the same day. R1's physician's report, dated 06/01/22, indicates that resident has diagnosis of parkinson’s (primary) and dementia (secondary) and cannot leave the facility unassisted. This was first AWOL incident for R1 since admission to the facility. R1 has been discharged to another facility for higher level of care. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore violations are cited today p er California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report and appeal rights provided to administrator.