Incident investigation·August 30, 2023

Licensing Program Analyst (LPA) De Leon conducted a case management deficiency visit to the facility above. LPA met with Ling Manuel and explained the purpose of the visit. LPA De Leon received an incident report from the facility dated 05/17/2023 stating Resident 1 (R1) went out in the backyard to sit in the sun and around 9:00 am R1 wanted to go for a walk leaving out the side gate and not telling staff. The gate was alarmed and 2 staff were present inside the facility, neither heard the gate alarm. Staff continued with staff duties inside the facility. At approximately 10:15 am the Arroyo Grande Police Department (AGPD) contacted the facility Administrator stating they had R1. Administrator went to the AGPD and picked up R1. AGPD stated to the Administrator that R1 was found on the ground by an unknown person which helped R1 by taking R1 back home only R1 could not remember where to go so the unknown person dropped R1 at the Chevron station in Arroyo Grande and AGPD was contacted. Administrator assessed R1 and R1 had no apparent injuries. Administrator asked R1 if they heard the alarm and R1 stated yes but once the gate shut R1 did not hear it any longer. R1 stated R1 was fine. Administrator told R1 that if R1 wants to walk R1 needs to let staff know. LPA De Leon requested additional information about the incident and a copy of R1’s LIC 602A physicians report, which indicated that R1 was not able to leave the facility unassisted. Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.