Incident investigation·May 27, 2025

On May 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a case management visit that was conducted on 5/15/25. LPA met with Resident Services Director, Edward DeWitt and explained the purpose of the visit. On 5/15/25, LPA followed up on an incident that occurred on 5/1/25 at 2pm, where care staff reported that they heard the patio door alarm sounding and noticed that Resident 1 (R1) had exited the secured memory care unit without staff supervision. R1 was found a half a block away from the facility. During the visit conducted on 5/15/25, LPA reviewed R1's file, interviewed staff and toured the facility. Based on the file reviewed, LPA observed R1's physician's report to indicate R1 has MCI, however the physician crossed out the section where it indicated whether R1 can leave the facility unassisted or not. Staff interviewed were not clear if R1 can leave unassisted. In addition, staff interviewed indicated R1 left the facility through the memory care outdoor terrace door to the outdoor terrace area and walked to the side of the terrace then left through the second door to get outside the facility. Based on observations, both door were observed to be delayed egress doors and both doors were observed to be in working condition. Staff interviewed were unsure how R1 left without staff noticing but believe that R1 left the facility unassisted during shift change. On 5/22/25, the facility received confirmation from R1's responsible party that R1's physician diagnosed R1 with dementia on 3/5/25. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D due to R1 leaving a secured unit unattended. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the Resident Services Director and a copy is provided with appeal rights.