Incident investigation·July 5, 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 Manager Itzayana Barba and Wellness Coordinator Jenna Purnell. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/21/2023). According to the LIC624: on 06/12/2023, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was returned to the facility later the same day, unharmed/uninjured. During today’s visit, LPA performed a facility tour / welfare check, verifying that R1 was indeed unharmed/uninjured. LPA also inspected the facility’s perimeter gates and tested their ability to self-close and latch. LPA then reviewed pertinent care and administrative records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 04/19/2022), R1 was diagnosed with “Senile Dementia” and their doctor determined that they were not able to safely leave the facility unassisted. According to the latest LIC603A Resident Appraisal (dated 03/24/2023), which Licensee performed on R1, they were described as “forgetful, confused, wanderer.” According to the latest Care Plan on R1, which Licensee authored for staff use, R1 was required to be “visually checked on frequently through the day and night to promote safety…” Based on records reviewed and staff interview: R1 resided in the facility’s memory care section, had a pattern of loitering near the facility’s locked perimeter gates (near the front of the facility), but was otherwise able tob be redirected by staff. Per management interview, R1 needed staff escort whenever they were outdoors, even if they remained on the facility yard/grounds. However, during the 06/12/2023 incident, staff did not witness R1’s elopement and were initially unaware that they were missing. R1 was located by a member of the public, who brought R1 back to the facility, unharmed. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Following R1’s return, staff discovered that a perimeter gate near the front of the facility’s main memory care building was not fully self-closing and latching, after being opened. The gate in question was repaired on 06/13/2023. A preponderance of evidence exists to show that Licensee did not provide needed observation to R1, which was material to R1’s elopement incident. During today’s visit, LPA observed that the facility’s memory care buildings utilized a “secured perimeter,” meaning that the perimeter exits and gates are locked from both the inside and the outside. Per review of the facility’s license from CCLD, and the facility’s latest Fire Clearance (dated 12-06-2019): the facility did not have prior approval/endorsement from the State Fire Marshall, or from CCLD, for use of a “secured perimeter.” Based on record review, and corroborated by manager interview: Licensee did not possess an LIC602 Physician’s Report (or equivalent medical assessment) on R1 which had been updated within the last year, as is required for residents who are diagnosed with a dementia (as is the case with R1). Deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC809-D pages). CCLD determined one of these violations resulted in the facility not complying with its approved Fire Clearance from the local fire authority. An immediate Civil Penalty of $500.00 is thus charged and is noted on the LIC421-IM. LPA issued a Technical Violation (TV) regarding reporting requirements/timelines. LPA also issued Technical Assistance (TA) regarding a self-closing mechanism on one of the facility’s perimeter gates in its assisted living section (which was not a contributing factor to R1’s elopement incident). An exit interview was conducted with Purnell, to whom a copy of this report, the LIC809-D pages, the LIC9102-TV, the LIC9102-TA, the LIC421-IM, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.