Incident investigation·February 7, 2023

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with Administrator Jennifer, explained the purpose of the visit. On 01/27/2023, the Regional Office received an incident report from WellQuest of Elk Grove. The incident report stated that a staff member, Staff 1 (S1), accidentally let a resident, Resident 1(R1), out of the memory care unity. S1 believed that R1 was a family member visiting a resident in the memory care unit. According to R1's records, R1 is diagnosed with dementia and is unable to leave the facility unassisted. The facility discovered resident was missing 50 minutes after S1 let R1 out. Video footage was reviewed and revealed R1 left the facility. Family and law enforcement was contacted. R1 was returned to the facility with the help of the fire department. Resident was assessed by EMTs and put on alert charting. According to the administrator, staff were immediately given an in-service training. LPA obtained copies of in-service training and list of staff attendance. LPA followed up on another incident report dated 02/01/2023. The incident report involved a resident that was observed to have a change of condition and was sent to the hospital. Resident has returned and is doing well. Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, a deficiency is be cited today on LIC 809-D. Appeal rights were provided. An exit interview was held, and a copy of the report was provided.