Incident investigation·July 26, 2023

On 7/26/23, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced Case Management visit to address concerns regarding a resident's elopement on 7/23/23. LPA met with Administrator, Kasie Wimmer and explained the purpose of the visit. Based on the incident report and review of resident's LIC 602, resident R1 has been determined to be unable to leave the facility unassisted by his physician. It was learned that R1 eloped from the facility through the rear gate of the building without staff knowledge. According to staff, R1 went out the back courtyard and went out the delayed Egress. Staff responded to the courtyard door and saw another resident by the door. Staff thought the female resident had triggered the alarm. Staff reset the alarm and the alarm also reset the Delayed Egress that was not supposed to happen. R1 was located by Management and returned to the facility where R1 was assessed to be without any injury. Per California Code of Regulations, Title 22, deficiencies are being cited on the attached 809-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations. Exit interview was conducted, a copy of this report, LIC 809-D and Appeal Rights were left at the facility.