Incident investigation·December 16, 2021

Licensing Program Analyst (LPA) Anthony Tuck arrived at facility unannounced on 12/16/2021 and was met by Staff Diana Garcia. Diana Garcia is the new Administrator. LPA explained the reason for today's visit to conduct a case management visit regarding an incident that occurred on 12/06/2021 involving a resident that resulted in an AWOL. LPA learned that resident (R1) was discovered by staff (S1) as missing at 4:00 AM on 12/06/2021 during night check rounds. It was learned that staff immediately notified the Administrator (Admin) and emergency dispatch was contacted to report the resident missing. It was learned from that R1 had turned off the alarm on the front door and left unnoticed. LPA learned that that the Admin contacted hospitals and drove around the area to locate R1, however R1 was not found. An additional incident report was received on 12/08/2021 containing updated information on the status of R1. It was learned that the Admin received a call from the Police on 12/07/2021 at 1:00 PM that R1 was found at his friends house in Rio Linda. LPA learned that the Admin picked up R1 and brought R1 back to the care home. LPA reviewed a copy of the LIC 602 form R1, it was learned that R1 is not allowed to leave the facility unassisted and has a diagnosis of Dementia and seizures. It was learned that S1 was on duty the night of the incident. LPA learned from an interview with Administrator that S1 is no longer employed with the facility. Based upon interviews with Administrator and R1 and review of documentation, per California Code of Regulations, Title 22 Division 6, Chapter 8, A Type B deficiency is being cited today in violation of California Code of Regulations and follows on 809D. Exit interview held with Diana Garcia and a copy of report given at the conclusion of the visit.