Incident investigation·May 10, 2023

On 5/10/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on an incident that was reported by the facility. LPA met with administrator, assistant general manager and resident care coordination and explained the purpose of today's visit. On 5/8/2023, LPA was notified by the resident care coordination that early that morning at around 12:30am, facility was notified by a hospital that resident # 1 (R1) was found, and appeared lost resulted the hospital visit. R1 was assessed at the hospital and the facility was informed that R1 was ready to return. According to facility directors, R1 is a resident residing in the memory care unit and during the incident, R1 left the unit from one of the egress exit doors which the alarm should have been triggered as the door opened. However, the alarm did not go off because the alarm was manually turned off by staff. In addition, facility directors stated that since the incident, facility has provided a one on one sitter for R1, in-serviced staff on resident elopement drill & response checklist, purchased additional device for an exit gate to alarm staff when someone leaves. During the case management visit, LPA toured the memory care unit, tested the egress doors and observed them to be adequate. When the alarm went off, staff responded it immediately. Based on interview, facility staff manually turned off the alarm on one the egress doors resulted R1 left the facility unattended. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with facility director. A copy of this report and the Appeal Rights is provided.