Incident investigation·March 22, 2024

On 03/21/24, at 9:00 AM, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a case management visit regarding a self-reported incident. The LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator (DFA). The MedTech on duty called the DFA and provided LPA with the file for the resident who eloped (R1)1 to review while waiting for the DFA. On 03/20/24, this facility faxed a report to Community Care Licensing (CCL) that R1 eloped from the community at approximately 8:05 PM on 03/19/24. The report goes on to state the following: The alarms were set off and staff immediately went out to search the neighborhood for the resident. After 5 minutes, the Administrator was notified, after 15 minutes, the responsible party was notified, and the police were notified immediately after that. According to the report that CCL received, R1 was located at 8:30 PM and brought back to the community. LPA conducted a tour of the facility upon arrival. The delayed egress door on the right side of the facility was not alarmed when this LPA exited the building. The gate to the right of the door had broken zip-tie slipped through the latch. LPA opened the gate and an alarm sounded. Maintenance staff re-entered the patio area from the opened gate. LPA continued her walkthrough. The facility was clean and not malodorous. Residents were friendly and offered hugs and smiles. LPA observed 4 Caregivers, 1 MedTech, 1 Cook, and 2 Maintenance/Housekeeping staff workers. The DFA arrived and a brief interview followed. LPA obtained the following documents: LIC 500, LIC 308, LIC 602 dated 01/29/24, Needs and Services plans dated 02/13/24 and 03/21/24. ID/Emergency Contact Information, and documentation from Alpha One refusing transport to the hospital. LPA conducted a second walkthrough with the DFA and again exited the rear on the right side. The alarm was still deactivated on the door. LPA set the alarm off on the rear gate adjacent to that door. The DFA and LPA were able to walk from that area, through the outdoor patio, back inside and to the front of the building where the DFA turned off the alarm. A review of records indicated that R1 was admitted to this memory care facility on 01/30/24, the LIC 602 stated that R1 was unable to leave the facility unassisted and R1 exhibited wandering behavior. The physician's report also stated that R1 was considered non-ambulatory based on their mental state. The facility was aware of the resident's wandering behavior prior to R1 being admitted. This LPA reviewed the Needs and Services plans that were completed prior to the elopement and post elopement. Both stated that staff would redirect R1 in order to prevent elopements. No new strategies were listed in the updated Needs and Services plan. This LPA interviewed R1 and found R1 to be intelligent, alert, and well-spoken. R1 was very fit and guided this LPA on a walk through the common areas. LPA and R1 activated the alarm on the rear back gate and 3 staff responded within 11 seconds. During the course of this investigation, this LPA learned that R1 has talked about or has tried to return home before but staff had previously been able to redirect R1. R1's behavior was not new, there was not a sufficient number of staff to meet the needs of this resident in care. According to the California Code of Regulations, Title 22, this deficiency has been cited on the LIC 809D page and a Civil Penalty was assessed for $500. On 06/12/25, this report was amended to change the citation from a violation of 87705(c)(4) under "Care of Person's with Dementia" to 87411(a) under "Personnel Requirements- General." A trainee (S3), without a walkie-talkie to communicate with coworkers, was sent to investigate the alarm. S3 had to go back to the other side of the building to inform the other staff that they could not locate the missing resident. Staff then had to determine which resident was missing before alerting the Administrator, the local police, the responsible party and Community Care Licensing. A copy of this report was provided along with Appeal Rights and signed by the Designee, as the DFA was out of the building. Exit interview.