Incident investigation·May 23, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/23/24 to do case management visit for Residents, R1 and R2 . LPA met with administrator Stephen Macdonald and explained the purpose of the visit. Incident for R1- Department followed up on Incident Report and SOC 341 sent by facility on 04/19/24 for an incident that occurred on 04/18/24 regarding resident, R1. Department conducted record review and interviews regarding this incident which occurred on 04/18/24 around 10.30 pm. Based on information gathered, it has been concluded that R1 advised staff they were not ready to lay down to go to bed however staff assisted R1 to their bed without R1’s consent which was a violation of Resident’s Rights per CCR, Title 22 Regulation, therefore Citation-A has been issued during this visit. Incident for R2- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 05/09/24 regarding resident (R2) leaving the facility (AWOL) unattended on 05/08/24 at approximately 07:30 pm. Per incident report, it was discovered that R2 exited from main lobby door and was outside for approximately 3 minutes. IR indicated that R2 was wearing a wander guard at time of incident which alerted staff that R2 left the premises. R2 was brought back to the facility by staff uninjured. Facility notified R2’s doctor and family regarding this AWOL incident. R2's physician's report (LIC602) dated 04/26/24 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Although no injuries resulted from R2’s AWOL, R2 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R2 resulting in R2 leaving the facility unassisted. 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. Deficiencies issued are noted on the LIC809D per Title 22 Regulations. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.