Incident investigation·June 21, 2024

Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Case Management visit to follow-up on an incident reported to Community Care Licensing. LPA met with Executive Director Rebecca Toves and discussed the purpose of the visit. Community Care Licensing received an incident report on 6/19/2024 in which it was reported that Resident #1 (R1) went absent without official leave (AWOL) from the facility on 6/13/2024. Staff was driving to the facility and circled the perimeters per usual route. Staff noticed that back gate was ajar and located R1 walking towards the facility. Facility staff were notified of gate being open per alarm on walkies. Staff failed to check back gate and clear alarm. During today's visit, LPA conducted a health and safety check of the residents in care and provided consultation. Deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Correction was jointly developed with the Toves. An exit interview was conducted with Sano, to whom a copy of this report, the LIC 809-D and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit