Incident investigation·June 7, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Resident Care Director Mikhail Grant. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/05/2023). According to the LIC624: on 06/03/2023, Resident #1 (R1), who resides in the facility’s secured memory care unit, briefly eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] R1 was quickly recovered by staff, unharmed/uninjured. During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA also reviewed pertinent care and business records and interviewed relevant staff. Due to their baseline memory loss and disorientation, R1 was not able to participate as a reliable interviewee/historian. Per their LIC602’s Physician’s Report (dated 10/17/2022), R1's primary diagnosis was “Alzheimer’s Disease,” and their doctor determined that they were unable to safely leave the facility unassisted. According to care records and corroborated by staff interviews: On the morning of 06/03/2023, R1 activated a 15-second delayed egress door within the facility’s memory care neighborhood, which allowed them to exit the building and walk to a nearby sidewalk. Staff #1 (S1) immediately heard the activated door alarm, but was slightly delayed responding to the door, because they were assisting another resident on the toilet. Staff #2 (S2) was already outside (taking their break), and soon saw R1 and escorted them back inside. R1 was only briefly unattended, and they were recovered without harm/injury. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] During today’s visit, LPA, accompanied by facility management, activated/tested each of the delayed-egress doors and courtyard gate associated with the facility’s “Reminiscence” secured memory care unit. All doors correctly locked and unlocked, and alarmed and reset, consistent with regulation. LPA observed: a) There were three delayed egress doors which led from the Reminiscence interior to and from the Reminiscence courtyard. These three doors were entirely missing the required signs which are described in California Health and Safety Code; b) The “Stair C” and “Stair D” doors were delayed egress going in both directions (in and out). However, these two doors had signs on only one side of the door; and, c) For those delayed egress doors and courtyard gate that did have the required signs, in all instances the signs themselves were not positioned within 12 inches of either the panic bar or the door latching hardware, as required. One (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee. LPA also provided Technical Assistance regarding staffing and licensee’s absentee notification plan/policy. An exit interview was conducted with Grant, to whom a copy of this report, the LIC811 Confidential Names List, the LIC9102-TA pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.