Follow-up·October 30, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to observe the physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Jared Green. On 07/06/2023, Licensee submitted a written request to the CCLD San Diego Regional Office (RO) applying for approval to lock perimeter fence doors and gates associated with the facility's two (2) memory care buildings, thereby creating a secured perimeter around those areas. The request did not involve locking other perimeter doors of the facility, and did not involve amending the facility's total capacity, bedridden capacity, or floor plan layout. On 09/08/2023, the local fire authority granted an updated fire clearance to the facility. The secured perimeter associated with the facility's memory care buildings was already present on the date of the fire inspection. The fire clearance gave approval for the secured perimeter. During today’s visit, LPA briefly toured facility, interviewed staff, and reviewed pertinent records. LPA verified that the current sketch/floor plan is consistent with the current layout of the facility, and that the facility’s posted evacuation routes have been updated to reflect the locked courtyard fence gate. Per review of the LIC624 Physician's Reports for the residents who live in the facility's memory care section: a) all were diagnosed with dementia or a similar neuro-cognitive disorder, and b) none had as their primary diagnosis a mental disorder unrelated to dementia. Licensee has also informed each resident's responsible person (where applicable) in writing of the use of secured perimeter in the facility's memory care section. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] In their interviews, staff confirmed: c) without violating residents' personal rights, they attempt to redirect residents who try to leave the facility, d) residents who still insist on leaving are allowed to leave, with staff accompanying them for safety, and e) staff understand that locked perimeter doors/gates are not a substitute for trained staff in sufficient numbers to meet the care and supervision needs of residents. Licensee has obtained from CCLD an approved waiver to California Code of Regulations, Title 22, Section 87468.1(a)(6). The facility’s disaster drill logs showed at least one drill per quarter was conducted on each of its three work shifts. Licensee’s Plan of Operation describes the facility’s locked perimeter fence gate. LPA observed no immediate health or safety issues. No deficiencies were cited during today's visit. This portion of the application process is complete. Pending CCLD management’s final review and approval, the licensee will be sent an updated license to reflect the new fire clearance. An exit interview was conducted with Green, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.