Incident investigation·August 3, 2021

Licensing Program Analyst (LPA) Adam Hamer conducted an unannounced Case Management visit on today's date regarding an Incident Report received by CCLD on August 2, 2021 for Resident #1 (R1) (See LIC 811 - Confidential Names List). LPA Hamer arrived at the facility and was greeted at the entrance by Caregiver Rolly DeGuzman. Then, LPA identified himself and disclosed the purpose of this visit which was to follow up on the Incident Report reporting the AWOL of R1. Administrator Jose Ricardo Ramirez later arrived at the facility and met with LPA. The Incident Report submitted to CCLD is dated August 2, 2021 and was submitted by Mr. Ramirez. The report reveals that R1 left the facility on July 31, 2021 and that, according to R1’s Physician’s Report, they can leave the facility unassisted. LPA Hamer reviewed pertinent information from R1’s file and received copies of facility records from the administrator, including records from R1’s file. LPA also reviewed the facility’s Absentee Notification Plan and the administrator also provided a copy to LPA. During the tour of the facility, w hen LPA walked into the kitchen, LPA observed and took pictures of several knives and other sharp objects accessible to a resident in care with dementia who was present in the kitchen area prior to LPA's arrival. LPA also observed and took pictures of cleaning supplies, including bleach and window cleaner, in two (2) unlocked cabinets in the kitchen area, both violations of California Code of Regulations, Title 22, Division 6, Chapter 8. (continued on LIC 809C) LPA observed deficiencies during today's visit and citations are being issued as detailed on the attached LIC 809D. An exit interview was conducted with Mr. Ramirez. LPA reviewed this report, the attached LIC 809D, including the administrator's plan of correction, the LIC 811 and Licensee / Appeal Rights (LIC 9098 01/16) with Mr. Ramirez. The documents were also emailed to Mr. Ramirez and he expressed to LPA that he would send a confirmation upon receipt of these documents.