Incident investigation·July 10, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident 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 an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 07/05/2023). According to the LIC624: on 07/02/2023, Resident #1 (R1) 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 found by staff shortly after and was brought back inside the facility unharmed. During today’s visit, LPA performed a brief facility tour and welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also reviewed pertinent care and administrative records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 04/26/2023), R1 was diagnosed with both “Major Neurocognitive Disorder” and “Dementia,” and their doctor determined that they were not able to safely leave the facility unassisted. Due to their baseline memory loss, R1 was not able to participate as a reliable historian/interviewee about the incident. Per LPA observation, the entire facility is a dedicated memory care unit, and the building utilizes delayed-egress exit doors, each of which currently unlock after 15 seconds. One such delayed-egress door leads from the facility’s second floor to the “South Stairwell,” and down to the facility’s parking garage, which then has a driveway leading back to the front of the facility, which faces the street “El Camino Real.” [CONTINUED ON LIC 809-C [CONTINUED FROM LIC 809] Per staff interviews: During the afternoon of 07/02/2023, Staff #1 (S1) heard the activation of the alarm on the second floor's "South Stairwell" delayed-egress door, and went to investigate. (Time and date-stamped electronic alarm logs showed the alarm was manually reset after 36 seconds.) S1 arrived at the now-unlocked door and checked the stairwell and parking garage. Upon seeing no resident in either location, S1 went back inside and called “all clear” on the radio to their co-workers. Licensee’s staff did not perform a resident head count and were initially unaware that R1 was missing from the facility. Approximately five (5) minutes after the alarm was reset, Staff #2 (S2) incidentally encountered R1 outside the building trying to get back inside. Based on the particulars of the incident, a preponderance of evidence exits to show that licensee’s staff did not have the training necessary to respond to delayed-egress doors in a way that preserved resident safety. Based on records review, and confirmed by management interview: Licensee did not possess a written Absentee Notification Plan on R1 at the time of the incident, as was required. Deficiencies were cited per California Health and Safety Code and California Code of Regulations, Title 22 (refer to the attached LIC809-D page). Plans of Correction were jointly developed with the Licensee. LPA also issued one Technical Violation regarding reporting requirements (refer to the LIC9102-TV page). An exit interview was conducted with Ancheta, to whom a copy of this report, the LIC809-D, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.