Incident investigation·January 17, 2024

Licensing Program Analysts (LPA) Dang Nguyen and Amy Rodgers conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Director of Resident Services Corinna Norton. Today's visit was in response to an LIC624 Incident Report, which Licensee self-submitted to the CCLD San Diego Regional Office (received on 12/28/2023). According to the LIC624: on 12/27/2023, Resident #1 (R1) left the facility and was unable to find their way back home. [See LIC 811 Confidential Names List for a description of R1.] Local police were called; later that same evening police brought R1 back to the facility unharmed. During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were unharmed. LPAs also collected copies of pertinent records and interviewed relevant staff and R1’s responsible person. According to R1’s latest LIC602 Physician’s Report (dated 11/17/2023), their doctor determined that although R1 had Mild Cognitive Impairment, they were still able to safely leave the facility unassisted. The doctor wrote that R1 was not confused/disoriented, had no wandering behavior, was able to follow instructions, was able to communicate needs, and was independent in all Activities of Daily Living (ADLs). Licensee’s own care appraisals on R1 (dated 11/22/2023 and 11/29/2023, respectively) corroborated that R1 was “active” and independent in all ADLs. Interviews and records showed: Licensee had a written Absentee Notification Plan, and that staff followed this plan during the incident. Licensee also notified R1’s physician of the incident and performed a timely reappraisal of R1’s care needs, as was required. Following the reappraisal, Licensee relocated R1 to its secured memory care section. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No deficiencies were cited during today's visit. LPAs issued Technical Assistance (TA) regarding the facility’s Absentee Notification Plan. An exit interview was conducted with Norton, to whom a copy of this report, the LIC9102-TA, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.