Incident investigation·November 26, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/26/24 to do case management visit for Resident, R1. LPA met with Assistant Director, Tosha Devi and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 11/04/24 regarding resident (R1) leaving the facility (AWOL) unattended on 11/02/24 at approximately 09:00 AM. Per incident report, it was discovered that R1 exited from main lobby door and facility was notified by one of their neighbors that R1 was located at their property around 09:30AM. R1 was brought back to the facility by staff uninjured. Facility notified R1’s doctor and family regarding this AWOL incident. R1's physician's report (LIC602) dated 01/19/24 indicates that resident has diagnosis of dementia and cannot leave the facility unassisted. Although no injuries resulted from R2’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted. Immediate Civil penalties of $250.00 were assessed on LIC421FC today due to repeat violations of the same regulations within 12 months for Regulation 87468.2(a)(4). Deficiencies issued are noted on the LIC809D per Title 22 Regulations. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted. Appeal rights were provided and copy of the report was provided.