Incident investigation·April 28, 2022

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/28/22 at 9:15AM. LPA met with Jennell Revera, Administrator and stated the purpose of today’s visit. Community Care Licensing (CCL) received an Incident Report (SIR) on 4/26/22 indicating that resident #1 (R1) left the facility without the knowledge of the staff. LPA requested, received and reviewed the most recent Physician Report (LIC602) for R1 dated 1/5/21. The LIC602 stated that R1 was unable to leave unassisted and has a diagnosis of Dementia. A review of R1's most recent assessment Individual Service Plan (ISP) dated 4/22/22 indicates that R1 utilized a wander guard that would be checked daily. It also indicated that R1 had a supervised elopement on 4/12/22 and an elopement on 4/22/22 during night shift. LPA conducted interviews of Staff #1 (S1) - (S5) and family of R1 during this visit. LPA received information that R1 eloped previously on 4/22/22. Administrator stated that the incident was not reported. Per the Administrator and the most recent assessment, effective 4/22/22, R1 was to receive 1:1 supervision during (NOC) shift hours of 10p-6am due to wandering behavior but the agency cancelled the shift at the last minute. Staff #2 (S2) was put in place for the 1:1 companion to ensure the supervision of R1. LPA toured the facility with Administrator. LPA observed with Administrator and S3 that the door did not alarm when pushed opened outward. S3 does a weekly check on day mode and now conducts weekly checks on night mode as well. LPA observed the room where R1 reside and the area that S2 was located to observe R1. Administrator stated that S2 did not look into R1's room as to be careful not to wake R1 as any disturbance would cause R1 to be awake all night. See 809C for continuation... Administrator stated that a visual from the common area camera shows that R1 was at the front door pushing it to leave at 11:03pm on 4/25/22. And it is assumed that S2 was outside R1's room at 10:55pm. There is no fee being charged for the 1:1 companion. R1 was last seen physically during medication pass on 4/25/22 at approximately 8pm. The SIR indicated that at 7:11am on 4/26/22, S4 noticed the front door opened. It also mentioned the alarm on the door did not activate. During a search of the facility and community R1 was located in a parking lot at 7:32am sitting on curb and pants were dirty by S5. R1 was observed to have sustained a scrape on one hand it is unclear which hand. Due to R1 eating, first aid was not provided. Right after the meal, R1's family arrived to take R1 on an outing. The investigation revealed that R1 eloped from the facility twice, one of which was not reported to CCL. On 4/26/22, R1 was out of the facility approximately 8 hours over night from 11:03pm 4/25/22 to 7:36am 4/26/22. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided. See 809D for continuation...