Incident investigation·March 20, 2024

Licensing Program Analysts (LPAs) Talwinder Bains and Lavinia Muscan arrived at the facility unannounced on 03/20/24 to conduct a case management inspection to follow up on a recent AWOL for residents, R1 and R2 at the facility. LPAs met with Executive Director (ED), Stephan Mcdonald and explained the purpose of the visit. R1’s AWOL Incident (1) - The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 03/05/24 regarding resident (R1) for date 02/26/24. Facility indicated R1 was at Winco around 3pm when R1 had change in condition which resulted in Winco staff calling EMS services. R1 was transferred to a local hospital and received medical care. R1 returned to the facility on the same day with no change. It is noted that Winco is 0.2 miles from the facility and is located across a busy street. The incident report and LIC602 (dated-07/19/21) were reviewed for R1 and it was discovered R1 has diagnosis of dementia and cannot leave the facility unassisted. The incident report submitted to the Department did not indicate that R1 was AWOL, only that EMS services were sought while R1 was out of the community. R2’s AWOL Incident (1)- Based on information provided by the facility, it was learned that R2 was at Winco with R1 on 02/26/2024. A review of R2’s physician report (LIC602, dated- 11/07/23 stated R2 has a diagnosed of dementia and cannot leave facility unassisted as well. The facility did not submit an incident report for R2’s AWOL. Although no injuries resulted from R1 and R2s AWOL incident on 02/26/24, R1 and R2s LIC602s indicate they were unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 and R2 resulting in R1and R2 leaving the facility unassisted. It has been determined that the facility did not report R1 and R2s AWOL on 02/26/24 therefore did not meet mandatory reporting requirements. In addition, record review indicated that facility does not has updated medical assessment for R1, who has a diagnosis of dementia. R1’s last LIC602 was dated 07/19/21. Based on Title 22 regulations, a resident with a diagnosis of Dementia shall have an updated medical assessment at least annually. Violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87411 and Regulation 87211. Exit interview conducted. Copy of report, appeal rights has been provided to ED.