Incident investigation·March 12, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director, Rachel Brown. The purpose of the visit is to follow-up on an incident report the Department received regarding a resident (R1) who exited the memory care unit through a delayed egress door and was found at the facility’s driveway. Based on the incident report, it was stated that a visitor observed the resident on the driveway and informed the concierge through the driveway intercom a minute after the resident had exited. The visitor immediately escorted the resident back to memory care. No injuries were noted, and resident’s condition was at baseline. Based on interview with the ED, it was stated that because R1 was attempting to exit seek throughout the day, the staff was turning the delayed egress door alarm on/off throughout the day. After R1's previous attempt to exit seek, the staff mistakenly did not reset the delayed egress door alarm resulting in R1 being able to exit seek without staff's knowledge. LPA observed that R1's bedroom is located near the exit door. ED states that R1 was not able to get past the gate alone as R1 was found by a visitor who was entering into the community, who then escorted R1 back to memory care. After the incident, resident was placed on monitoring for 72 hours, facility staff reached out to R1's doctor regarding possible medication changes, informed R1's authorized representative, and updated R1's care plan. All staff was retrained on elopement prevention, including management of wandering behavior and delayed egress doors. The facility also has on-going elopement drills. Page 1 of 2. The facility plans to change their delayed egress door alarm from a key to a number pad to help prevent the same incident going forward. During visit, LPA obtained R1's physician's report, service plans, progress notes, and staff training records. Based on record review, the facility completed an updated service plan dated 03/07/25 which includes interventions in place for R1's exit seeking to include accompanying R1 to activities and meals, and notifying the nurse when R1 exit seeks. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director, Rachel Brown and a copy of the report was provided. Page 2 of 2.