Incident investigation·September 8, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today. LPA Rai met with Director of Health Services (DHS) Adriana De La O and stated purpose of today's visit. The purpose of the case management visit was to follow up on an incident which occurred on 8/17/2023 at 9:37pm when resident (R1) cut off the wander guard and left the facility unassisted on the electric scooter. Per Incident Report, the facility received a phone call from R1's child stating R1 was out of the facility and approximately 7 miles away from the facility. The incident was reported to the Department via Unusual Incident Report on 8/17/2023. During today's visit, LPA Rai interviewed DHS and two staff (S1-S2). DHS stated R1's child informed the facility about R1 was out of the facility unassisted and 911 was called. Law enforcement officers were with R1 and DHS met with them before they escorted R1 back to the facility. R1 informed DHS of cutting the wander guard from the scooter before leaving the facility from the front door. Upon arrival back to the facility, DHS and facility staff found the wander guard in R1's room. DHS believes R1 left the facility from the front door when staff were not present at the reception area. Per DHS, the receptionist is at the reception area until 8pm and after 8pm a security guard will take over the reception area. R1 has left the facility previous to this incident on 10/6/2022 and R1 had cut the wander guard before leaving the facility unassisted. Per DHS, R1 does not have cognitive impairment and R1 does have cognitive abilities to make decisions. Per R1's Resident Appraisal 8/30/2023, R1 needs special observation/night supervision due to confusion, forgetfulness wandering and it stated "Resident has wander guard". Per record review of R1's Physicians Report 8/4/2023, R1 is unable to leave the facility unassisted and R1 uses a motor scooter due to motor impairment. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. Based on the interviews, the day of the incident 8/17/2023, the facility staff were not aware resident had left the facility until R1's child informed the facility staff. R1 was being tracked by phone and was showing location approximately 7 miles away. The facility staff last saw R1 during dinner time at 6pm and DHS had last seen R1 at 7pm when R1 was done with dinner and back to the room. At 8pm, S1 went to R1's room to administer medications, R1 was not found in the room and the room lights were off. S1 assumed R1 was with family even though the log did not show R1 was signed out of the facility. 2 of 2 staff stated residents' families will often not sign out residents out of the facility, even though it is a facility policy. At 9:37pm, S2 received the phone call from R1's child, informing R1 was not at the facility and notified S2 that R1 was approximately 7 miles away and was alone and unassisted. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. LPA Rai spoke with Director of Health Services (DHS) Adriana De La O and Executive Director Randy Herzig and went over report and today's deficiencies and they both agreed and understood. Exit interview was conducted with Director of Health Services (DHS) Adriana De La O and a copy of this report was provided. Appeal Rights were provided.