Incident investigation·January 24, 2024

Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Interim Executive Director Becca Black. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (it was received on business day 01/22/2024). According to the LIC624: on 01/13/2024, Resident #1 (R1) eloped from the facility (left without staff supervision). [See LIC 811 Confidential Names List for a description of select person identifiers used.] Facility staff located R1 the same day, and returned them to the facility, unharmed. During today’s visit, LPAs performed a brief facility tour and welfare check on R1, verifying that they were indeed safe. LPAs also collected copies of and reviewed pertinent records and interviewed relevant staff. According to their latest LIC602 Physician’s Report (dated 07/19/2023), R1 was diagnosed with Dementia and their doctor determined that they were not able to safely leave the facility unassisted. The multiple care appraisals which Licensee performed on R1, since the time of their move in, corroborated these points. Due to their baseline memory loss, R1 was not able to serve as a reliable historian/interviewee for this case. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Staff interviews unanimously showed: Around midday on 01/13/2024, R1 entered the facility’s lobby and stated to Staff #1 (S1) and Staff #2 (S2) their intent to leave the facility on foot. S1 freely allowed R1 to leave, unescorted, via the front door. S2 witnessed this, had concerns about it, but did not correct/stop S1 from letting R1 leave. S2 subsequently conferred with other staff, who reinforced that R1 could not be out in the community by themselves. Staff then used vehicles to search for R1. S1 subsequently located R1 and returned them to the facility unharmed. During the incident, R1 was unsupervised for about a half hour. Staff interviews further showed: Following the incident, Licensee conducted an internal investigation which found that the root cause of the incident was “training” (i.e., S1 did not have a clear understanding of R1’s cognitive limitations and whether R1 was allowed to leave the facility unassisted). Licensee’s staff first told R1’s physician and responsible person (RP) of the AWOL incident on 01/17/2024, which was four days after the incident. Licensee did not send a copy of the written incident report to the RP, as was required to be done within seven days. Licensee’s submission of the written incident report to CCLD was also late. During records review, LPAs observed (and manager interview confirmed) that Licensee did not possess a written Absentee Notification Plan (or equivalent missing resident policy) for C1 or the other residents in care, as was required. Two (2) deficiencies were cited per California Code of Regulations, Title 22. One (1) deficiency was cited per California Health and Safety Code. (Refer to the attached LIC 809-D pages). Plans of Correction was jointly developed with the licensee. An exit interview was conducted with Black, to whom a copy of this report, the LIC809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.