Incident investigation·March 29, 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 Business Office Manager Rebecca Toves. LPA also met with Executive Director Emily DeLaBarre, who arrived later during the visit. Today's visit was in response to a self-reported LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 03/27/2023. Per the report: on 03/20/2023, Resident #1 (R1) had an AWOL (absent without leave) incident. [See LIC 811 Confidential Names List for a description of person identifiers used in this report.] Facility staff did not see or hear R1 leave. Upon recognizing R1 was missing, staff unsuccessfully searched the facility building and surrounding areas before calling law enforcement. R1 was found a few hours later by personnel at a neighboring business, who returned R1 to the facility unharmed/uninjured. During today’s visit, LPA briefly toured the facility and performed a welfare check on R1, verifying that they were indeed unharmed/uninjured. LPA interviewed R1 and relevant staff. LPA also reviewed pertinent administrative, care, and medical records. According to R1’s latest LIC602 Physician’s Report (dated 02/01/2023), to the stock question about whether R1 was “able to leave the facility unassisted,” their doctor checked “yes.” However, the same doctor also diagnosed with R1 with “Mild Cognitive Impairment,” indicated they were wheelchair-dependent, and noted they could not independently manage cash or medications. Manager interviews confirmed that prior to the incident in question, R1 was assessed as not able to safely leave the facility unassisted. During interview, LPA observed that R1 was wheelchair-bound and disoriented to time and place (i.e., R1 was unable to state the city they were in, unable to state the year, and unable to name the U.S. President). Due to their baseline disorientation, R1 was not able to participate as a reliable historian/interviewee in this investigation. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] According to the facility’s own absentee notification plan (i.e. “Clinical Policy & Procedure Manual – California, Clinical 10 – Elopement”): all residents are screened prior to admission to determine their elopement risk. In the event a resident is believed to be missing, “an immediate systematic search of the property and surrounding neighborhood will take place,” and “law enforcement will be notified of [the] elopement within 30 minutes, should the resident not be located.” According to records and corroborated by staff interviews: On 03/20/2023 around 5:00 AM, Staff #1 (S1) was the first to observe that R1 was not present inside the facility. S1 alerted coworkers, who joined the search. However, it was not until about 7:15 AM that any staff phoned law enforcement for assistance. The neighboring business located R1 in their own parking lot around 7:30 AM, and returned them to the facility around 8:20 AM, concurrent with police officer(s) visiting the facility. CCLD determined that because staff did not follow licensee’s own absentee notification plan, law enforcement resources/reinforcement were delayed by around 1 hour and 45 minutes, which was detrimental to the search for R1. Staff interviews confirmed that R1 used their wheelchair to leave the building and that it was raining on the date of the incident. During today’s visit, LPA observed a perimeter exit door located within a first-floor stairwell (i.e., “Stairwell 1 Exit Route”), which leads directly outside. Neither the door to access this stairwell, nor the door within it which leads outside, were equipped with an “auditory device or other staff alert feature.” Per manager interviews, aside from R1, there also exist other current residents with memory impairment (and for whom exiting would present a hazard), who have direct access to the perimeter door in question. Deficiencies were cited per California Health and Safety Code and California Code of Regulations, Title 22. (Refer to the attached LIC 809-D). Plans of Correction were jointly developed with DeLaBarre. An exit interview was conducted with Toves, to whom a copy of this report, the LIC 809-D, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.