Incident investigation·May 24, 2022

On May 24, 2022, Licensing Program Analyst (LPA) conducted an unannounced case management visit. L PA met with interim Administrator, Robert Snee, and Director of Health Services, Glynis Marcantel joined shortly thereafter. LPA explained the purpose of the visit. The licensee reported on May 13, 2022, Resident (R1) was observed by the front receptionist to be walking toward the main office. According to R1, it was indicated at first that he/she jumped over the fence, however R1 then stated he/she had walked through the gate. There were no injures noted. During the case management visit, LPA interviewed staff and reviewed R1's files. According to the file reviewed, it indicates that R1 has dementia and is unable to leave the facility unassisted. According to the staff interviewed, it was indicated that the latch on the gate may not have been latched all the way resulting to R1 walking out of the facility. Facility immediately conducted a head count of all residents and checked to ensure all the gates were locked. In addition, the facility had a locksmith company come and perform an inspection of all gates to ensure they were locked and latched properly, however, these precautions were conducted after R1 was able to leave the facility. Section 87411(a) Personnel Requirements, requires that facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary care and supervision to meet resident needs. In the above incident, there was an absence of supervision resulting in a resident leaving the facility. 87411(a) Personnel Requirements- $500 CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION WITHIN 12 MONTHS on 2/24/2022. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Robert Snee, and Glynis Marcantel and a copy will be provided with appeals rights.