Incident investigation·August 4, 2022

Licensing Program Analyst (LPA) Tung Truong arrived at the above facility to complete a Case Management visit. LPA met with Interim Administrator Stephen Sarine and explained the reason for the visit. The purpose of this visit is to follow up on an incident report submitted for R1, detailing an AWOL from the facility on 7/25/2022. R1, a dementia resident, AWOL'd from the facility on 7/25/2022 at approximately 11:45pm. R1 exit the delayed egress and through the front door of the building. R1 was outside of the building for roughly 9-10 minutes according to staff. R1 rang the bell for staff to unlock the door. According to Administrator, R1 did not leave the facility premises. The Administrator discovered that the delayed egress door was not latched properly. The Administrator acknowledge of the Absence without Leave (AWOL) of R1. Upon a review of the most recent Physician Report (LIC602) dated 3/19/21, it indicates that R1 is not able to leave the facility unassisted. LPA learned that there were three staff on duty but no staff was there to redirect R1 from exiting the building. During today's visit, LPA learned that the delayed egress door has been fixed and staff have completed in-service training on frequent checks, egress, alarm and door secure awareness. Deficiencies were observed and cited on the LIC 809-D pursuant to the California Code of Regulations, Title 22, and California Health and Safety Code. Exit interview conducted, a copy of the report and appeal rights given.