Incident investigation·October 27, 2023

Licensing Program Analyst, Amber Coleman, (LPA) arrived at Allara Senior Living Facility, Residential Care Facility for the Elderly to conduct a Health and Safety Case Management Visit. This Case Management visit is in response to a Special/Unusual Incident Report, (SIR) called into the Community Care Licensing Office by voicemail on 10/26/23. LPA met with Business Office Manager, Helen Jaquez, introduced self and stated purpose of the visit; which is to gather more information about the incident and surrounding events. The incident reported occurred 10/26/23 at approximately 5:30pm, R1 departed the facility through an unlocked door of the Memory Care Unit. R1 walked to the main street (19th Street) was witnessed by a bystander who contacted the Police. The Police transported R1 to the station, contacted the facility to confirm, and returned the resident back to the facility. Today's visit consisted of a walk through of the Memory Care Unit, observation of the door and route R1 used to depart facility, staff interviews and record reviews. According to staff interviews, on 10/26/23 during the 2pm to 10pm shift; there were 4 staff members assigned to the floor. At approximately 5:30pm, 2 staff left the floor for break. Leaving 2 staff members on the floor. There were no witnesses to the resident's departure. LPA was informed that the memory care unit is a secure unit. When the door is opened an alarm is supposed to sound, but the door alarm failed. Its unknown how often the doors and alarms are checked. At this time, parts have been purchased to fix the alarm and staff is in the process of contacting the alarm company to schedule an appointment. Until the door, lock and alarm can be fixed, a staff member has been stationed to the door. Resident checks have been increased to provide rounds or checks every 30 minutes. R1 was assessed upon the return to the facility. According to staff, R1 had no apparent injuries to her person. Please see LIC809-C At approximately 2:30pm LPA was provided a copy of R1's Physician's Report. LPA observed that the document was missing a signature of the R1's representative. The report indicates R1 cannot leave the facility unassisted. Mental condition includes wandering. Based on observations, record reviews and staff interviews deficiencies will be cited to address the above mentioned concerns.