Incident investigation·April 28, 2023

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Jill McDonald. Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 04/25/2023. According to the LIC624: Around 4:30 AM on 04/21/2023, Staff #1 (S1) observed that Resident #1 (R1) was not present inside their bedroom. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] S1 alerted coworkers, who helped them search for R1. Staff subsequently located R1 just outside the facility’s building. R1 said they felt cold and had a minor bruise on their left elbow, but they were otherwise uninjured/unharmed, as confirmed by paramedics who later assessed R1. During today’s visit, LPA performed a brief tour and observed the facility’s perimeter exit doors. LPA also reviewed pertinent records and interviewed R1 and relevant staff. Due to their baseline disorientation to time and place and their memory loss, R1 was unable to participate as a reliable interviewee/historian about specific details of their AWOL (absent without leave) incident. However, R1 remembered some details about incident, said their elbow felt fine, confirmed they indeed were unharmed/uninjured, and stated they would not leave unassisted in the future. According to R1’s LIC602 Physician’s Report (dated 08/08/2022): R1’s primary diagnosis was “Dementia” and their doctor determined that they were “confused/disoriented” and were not safe to leave the facility unassisted. The Pre-Placement Assessment (dated 08/23/2020), the Functional Assessment (dated 03/18/2021), and the Needs and Services Plan which licensee prepared on R1, all corroborated that R1 had Alzheimer’s type Dementia and was not safe to leave the facility unassisted. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] According to licensee’s own absentee notification plan (i.e., sections “Clinical 10 – Elopement” and “MC-PO 05 – Missing Resident” from their policy and procedure manual): when staff cannot locate/account for a given resident, they must conduct a “systematic search of the property and surrounding neighborhood” and notify “law enforcement authorities…within 30 minutes, should the resident not be located.” According to staff interviews, and corroborated by electronic date/time stamped progress notes: On 04/21/2023, S1 saw R1 asleep inside their bedroom around 3:30 AM. Around 4:30 AM, S1 returned to the bedroom but could not find R1. S1 alerted coworkers, who started searching for R1. Law enforcement was not called to assist. Around 6:06 AM, staff found R1 sitting on the ground outside the building near an exit stairwell, unharmed/uninjured except for a minor elbow bruise. It was not until after R1 was located (i.e., after 6:06 AM) that facility staff first called 911. Paramedics physically assessed R1, who (along with their responsible party) declined transportation to the hospital. CCLD concluded that facility staff did not follow the facility’s absentee notification policy during this incident, resulting in law enforcement search resources not being leveraged to help find R1. Records showed that after the incident, based on reassessment, R1 relocated to the facility’s secured memory care section on 04/22/2023. Within the facility’s assisted living section (located on the 2 nd and 3 rd floors): LPA observed two unlocked (2) perimeter exit doors (accessed via unlocked stairwells near Room 202 and Room 235, respectively). Absent from each of these doors was either an "auditory device" or other "staff alert feature.” Staff interviews further revealed: the facility’s receptionist desk (which has line of sight to three perimeter exit doors located in the lobby) is normally manned/supervised between the hours of 8:00 AM and 8:00 PM. After 8:00 PM, two (2) of the three (3) lobby perimeter doorways are locked from the inside, but one (1) doorway (i.e., the main entrance) remains unlocked from the inside, as is consistent with the facility's approved fire clearance, but does not feature an “auditory device” or other “staff alert feature” being armed/used. Per LPA observation, record review, and staff interviews: during the AWOL incident in question, R1 lived in the facility’s assisted living section and had direct access to both of the above stairwell doors and the main lobby entrance door. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Within the facility’s secured memory care section (which licensee calls “Legacies” and located on the 1 st floor): LPA observed one (1) delayed-egress door gate (located inside the Legacies courtyard) which did not have the required sign described in California Health and Safety Code (HSC). LPA also observed that three (3) interior delayed-egress doors had the required signs, but the placement/position of the signs themselves did not meet HSC requirements. LPA also observed that multiple living units located inside the facility’s memory care section did not feature pull cords or a similar “signal system,” as required. Per interview of facility management, the living units inside the memory care section did not feature such devices. During today's visit, LPA, accompanied by facility management, tested the operation and alarms of multiple delayed egress doors. In all instances, staff responded to the door locations quickly to investigate the source of the alarms. Two (2) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee. An exit interview was conducted with McDonald, to whom a copy of this report, the LIC 809-D pages, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.