Incident investigation·September 5, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/05/24 to do case management visit and met with Staff, Sevrena Miller and explained the purpose of the visit. Based on Incident Report (LIC624) dated 08/29/24 sent by facility to Department, it was indicated that Resident, R1, was found missing by staff around 6:45PM during routine checks. It was learnt that R1 had returned from hospital the same day around 1:30PM, where R1 was treated for mental disorder. Per staff, R1 was doing fine after returning from hospital and took their medications and meals till R1 was found missing around 6:45PM. Staff searched R1 on facility’s property and surrounding areas but could not find R1. Administrator was notified and staff called 9-1-1 and sheriff around 7pm. Per facility records, missing person report was filed under case number, 24-78100. It was also learnt that R1 use to leave facility in the past and R1s LIC602 signed by thier physician indicated that R1 can leave Unassisted, but Authorities made the Alarm for missing person due to R1s mental health issues. During today’s visit, LPA was informed by staff that R1 was found uninjured on 08/30/24 by law enforcement and currently was at mental health care facility and getting the medical treatment with unknown discharge plan. Facility was in touch with R1s responsible party, social worker and other required parties per regulations regarding R1s health updates. During record review and staff’s interviews, LPA found that R1 was hospitalized one week prior to this incident where R1 received the treatment for their mental disorder and was in hospital for seven days and returned on 08/29/24. This incident should have been reported to Department per requirement, but facility did not report this incident. Based on this information, per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached LIC809-D page. Exit interview was conducted, copy of this report and appeal rights were provided. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.