complaint·August 12, 2022

Allegation: Staff did not provide adequate supervision to resident while in care. The department conducted interviews regarding resident (R1) leaving the facility unattended on 03/28/22, at approximately 5:00am. Facility administrator and staff confirmed R1 was gone approximately 30-40 minutes. Based on interviews, once staff realized R1 was missing, Facility staff found R1 about 2 blocks from the facility and brought R1 back to facility. Facility called 9-1-1 to notify of R1’s AWOL. However, once R1 was located, the facility called off EMS. Facility was aware that R1 has diagnosis of dementia and cannot leave the facility unassisted. This was the first AWOL incident for R1 since his admission to the facility. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Allegation: Licensee did not do a proper assessment of resident. The department conducted interviews and records review regarding proper assessment was not completed for resident (R1) by facility. During interview, facility administrator stated that R1 was admitted to facility on 03/27/22. Per Administrator, R1’s responsible parties were supposed to come to facility on 03/28/22 to finish all new admission paperwork. It was concluded that no pre-admission assessment or new admission paperwork was completed by facility per RCFE requirement on/before R1 admission to the facility on 03/27/22. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page. Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Allegation: Facility alarm was not working properly at the time of resident's AWOL /Elopement incident. The department interviewed facility administrator regarding this allegation.Administrator stated that facility alarm system had no issues and it was working fine. Per Title 22 regulations, RCFE does not require to have any working alarm system for facility to take care of residents in care. However, facility needs to provide proper care and supervision for residents in care, which facility did not do since R1 was able to AWOL from the facility on 03/28/22. Allegation: Facility did illegal eviction of the resident. The department interviewed facility administrator regarding this allegation. Based on record review and interviews, department has concluded that R1 was admitted to this facility on 03/27/22 and was sent out to hospital on 03/28/22 after a fall incident. Facility did not verbalize anything to the hospital or R1’s family that R1 could not come back once he got discharged from hospital. There was no notice of any eviction provided to R1 and/or R1’s responsible party. Based on interviews and records reviewed, the above allegations are found to be UNFOUNDED . A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. A copy of this report has been provided to facility. Exit interview conducted. Allegation: Resident has AWOL/ Elopement incident from the facility sustaining an injury to the resident. R1 was admitted to this facility on 03/27/22. Within the 24-hour time frame, R1 had two incidents; R1 AWOL’d from the facility on the morning of 3/28/2022 and was found shortly after. Facility called EMS but EMS did not take R1 to hospital after R1 was evaluated and first aid was provided. On the same day (03/28/22) around 3pm, R1 had what was believed to be a ground level fall from R1’s bed to the floor. Facility contacted 9-1-1 and R1 was taken to hospital for treatment. Upon R1’s arrival to the hospital, R1 sustained a right sided subdural hematoma, laceration on upper lip and frontal scalp hematoma. Based on medical records reviewed, it is unclear to determine if the injuries R1 sustained were due to the AWOL or the fall. Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED . A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.