Incident investigation·August 20, 2024

On 8/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management, following up on facility incident report. An incident occurring on 8/17/2024 involving resident (R1) leaving the facility unassisted. LPA toured the facility and interviewed Director of Residential Services, Linda Ishii. Based on interview, R1 had not previously demonstrated this behavior or desire to leave the facility site. The facility contacted appropriate parties including local police department and R1's POA and submitted an incident report to CLLD. R1 had been located at the local medical center in close proximity to the facility. R1 was assessed and found no signs of injury or changes of condition and safely returned. Based upon a review of R1's records, it was found that R1 is cleared by their physician to leave the facility unassisted and does not have a diagnosis of dementia. LPA and Administrator discussed several items following the incident, including supervision and reassessments for R1, in order to prevent further incidents from occurring. Facility to provide LPA with copies of R1's updated records once completed. In addition, LPA and Director of Residential Services discussed request for Fire Clearance Inspection. LPA was provided request documentation. Facility to provide updated facility sketch prior to LPA submitting inspection request to local fire department. No deficiencies cited during today's visit.