Incident investigation·June 20, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/20/24 to conduct a case management to follow up on a recent AWOL at the facility for resident, R1. LPA met with facility Administrator , Danielle Shanklin and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 06/04/24 regarding resident (R1) leaving the facility unattended on 06/03/24, at approximately 6:30 pm. IR stated that R1 got lost while on walk outside the facility after having dinner with their family member around 06:30pm. IR indicated that R1 was found lost on close by street by facility by bystander who notified law enforcement around 07:20pm and R1 was brought back by them uninjured to the facility. R1's physician's report, dated 02/17/24, indicates that resident has diagnosis of dementia (primary) and cannot leave the facility unassisted. This was first AWOL incident for R1 since admission to the facility. R1 has been discharged to another facility for higher level of care. Although no injuries resulted from R1’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 therefore violations are cited today p er California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report and appeal rights provided to administrator.