Incident investigation·August 5, 2024

Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to initiate a case management visit. LPA Lopez identified herself and was granted entry by Sharon Hays, Activities Coordinator. LPA Lopez stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Jay Agustin. This visit was in response an Unusual Incident/Injury Report (UIR) that was received at the San Diego Regional Office on Thursday, August 1, 2024. Per the UIR the incident transpired on Tuesday, July 30, 2024, with resident #1 (R1) who eloped from the facility. During today's visit LPA Lopez spoke with staff and resident, and requested and obtained relevant documents pertinent to this incident. According to staff, the resident was last seen on the facility premise at around 11:40 AM prior to their mealtime which was between 12:00 PM and 12:15 PM. According to Executive Director, he last observed resident to be at the facility at around 11:40 AM prior to his departure. About 30 minutes later, he was contacted by the family who made him aware that the resident had eloped and was with law enforcement. Resident was returned to the facility the same day with no injuries. R1's Needs and Service Plan was discussed and updated with the family. Per the Executive Director, R1 recently moved-in on July 29, 2024. The Executive Director mentioned that staff conduct visual resident head counts during all mealtimes – three times and monitor during incontinence checks– at least about twice and/or on an as needed basis. Records confirmed that the resident’s move-in date was recent. The incontinence sheets, for 7/30/24, show R1 incontinence time was left blank along with four additional residents for the time frame in question, but per ED it was due to residents not needing incontinence assistance during that time frame. Residents Physician’s Report confirms that the resident is an elopement risk. In review of the residents file, the resident did not have an elopement plan in place. Per the residents Needs and Service Plan, the elopement risk was implemented into R1’s plan on 7/31/24. (Continuation on LIC809-C) (Continuation of LIC809) According to the Executive Director, as of 7/30/24, the facility implemented a meal check sheet for residents to be accounted for during their mealtimes and in-between times. The facility did conduct in-service training to all staff for elopement. A copy of the forms and training sheets were provided to LPA during the visit. Based in the information obtained during the visit, there is a deficiency being cited during today’s visit that may be found on the LIC809-D page of this report. An exit interview was conducted with Executive Director Jay Agustin, and a copy of this report, LIC811 and Licensee Appeal Rights (LIC9058) were provided to Executive Director Agustin, at the conclusion of the visit. The signature below confirms that the documents were received.