Incident investigation·June 16, 2022

On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an case management visit regarding two incidents that were reported to CCLD. LPA met with Resident Care Director (RCD), Ed Dewitt and explained the purpose of the visit. The Licensee reported on 5/26/22, that there was a medication mismanagement that occurred and was discovered in the Wellness Center. During the visit today, LPA interviewed the Resident Care Director (RCD) and observed the Wellness Center. The Wellness center is located on the 1st floor and is locked at all times. According to the RCD, the missing medication (1 tablet) went missing sometime between the end of the PM shift and the beginning of the NOC shift. The facility conducted an immediate investigation, however did not find the missing medication. The facility has no priors of medication mismanagement. RCD trained med-techs regarding medication count and provided LPA with a completed log of an in-service training. On June 13, 2022, the facility reported that one resident #1 (R1) AWOL (Absent Without Official Leave) on 6/3/2022. During the visit, LPA reviewed R1's file and interviewed staff. According to the files reviewed, R1 has memory changes and has mild cognitive impairment (MCI). In addition, documents reviewed also indicated that R1 is unable to leave the facility unassisted. According to the interviewed staff, R1 was seen in the dining room around 6:30pm before AWOL. R1 was missing for about an hour and returned to the community by her responsible party. Based on interviews, and record review during the course of the investigation, the facility did not ensure basic services were being met, due to lack of supervision, R1 AWOL. Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed. This report was reviewed and discussed with Resident Care Director, Ed Dewitt, and a copy is provided. Appeals Rights were given.