Incident investigation·February 11, 2025

On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that occurred on January 29, 2025. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit. On 1/29/25, the Licensee reported, Resident 1 (R1) eloped from the facility. At 10:30am, the Daly City Police Officer came to the facility to report that R1 was found on the street and that he/she fell out of his/her wheelchair and smelled like alcohol. The police had a hold on him and took him to the hospital. All required parties were notified. During the visit, LPA reviewed documents and interviewed administrator. LPA observed the resident sign-in and sign-out log located in front of the nurse's station. According to the log observed, R1 did not sign out when he/she left the facility. Administrator indicated that R1 left from the upstairs back door. Based on file reviewed, R1's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted. According to the Licensee, the med-tech on duty gave R1 his/her medication around 8:30am/9am in R1's bedroom, however after that staff did not observe R1 leave the facility. The facility failed to provide care and supervision as necessary to meet the needs of R1 which resulted into R1 eloping from the facility from the back door and resulting in R1 having a fall while in a wheelchair. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). Report is reviewed with the administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.