Incident investigation·October 3, 2024

Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres, and we discussed the purpose of the visit. Community Care Licensing received an incident report on 9/23/4 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 9/21/24. According to records, R1 was observed leaving with an outside source vendor at 1:45pm, at 2:15pm the facility received a phone call from emergency personnel explaining R1 had been found away from the facility. According to interview with Staff present on the date of the incident, staff did not recognize R1 as a resident of the facility and did not prevent R1 from leaving the locked memory care unit. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. A deficiency is being cited for California Health and Safety Code. An exit interview was conducted with Business Office Manager Amanda Pepin and Clinical Director Yolanda Torres who was also provided a copy of their appeal rights (LIC9058 03/22), LIC811, LIC809 D and this report were provided to.