Incident investigation·April 11, 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 Executive Director Stefanie Ancheta. Today's visit was in response to the self-reported AWOL (absent without leave) of Resident #1 (R1) received in the San Diego Regional Office on 04/03/2023. [See LIC 811 Confidential Names List for a description of R1]. According to the report, R1 activated a delayed-egress exit door and then went down a stairwell and exited into the facility’s parking garage/lot. A bystander saw R1 there and alerted facility staff, who escorted R1 back to the facility. R1 was unharmed/uninjured. During today’s visit, LPA performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA briefly toured the facility and observed/tested the facility’s six (6) delayed-egress exit doors. LPA also interviewed pertinent staff, provided Technical Assistance regarding best practices for elopement drills, and reviewed a relevant staff training document. LPA observed that all six (6) of the facility’s delayed-egress exit doors featured highly visible exit signs with the required verbiage and text size, as described in California Health and Safety Code Section 1569.699(a)(7). However, for two (2) of these doors, (known as “1 st Floor South” and “1 st Floor North," the location of the required sign exceeded 12 inches from the panic bar or door latching hardware. One deficiency was thus cited per California Health and Safety Code (refer to the attached LIC 809-D). An exit interview was conducted with Ancheta, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.