Incident investigation·February 5, 2025

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Co-licensee Michael Vu (Co-LCN). The purpose of today's visit is to follow up with the incident report that Community Care Licensing (CCL) office received on 01/27/2025. On 01/24/2025, around 11:00AM, resident R1 was found missing in facility. R1 was last seen in his/her room on 01/24/2025, around 10:00AM. Facility staff S1 and S2 checked the facility inside and out, but were unable to find R1. S1 went out to search for R1 in the neighborhood but was unable to find R1. S2 called Licensee to notify the incident. Licensee called 911 at 11:15AM. LPA interviewed staff S1. S1 stated on 1/24/2025, resident R1 was seen at his/her room around 10:00AM. S1 stated at 11:00AM, he/she checked R1 again but was unable to find R1. S1 stated he/she and staff S2 checked the facility inside and out but were unable to find R1. S1 stated he/she went out to search for R1 in the neighborhood but was unable to find R1. LPA interviewed staff S2. S2 stated on 1/24/2025, between 10:00AM to 11:00AM, he/she was helping other residents in resident bedrooms. S2 stated he/she was notified by S1 that R1 was missing. S2 stated he/she and S1 searched for R1 but were unable to find R1. S2 stated he/she called R1' family and licensee. LPA interviewed Co-licensee (Co-LCN). Co-LCN stated on 1/24/2025 around 3:00PM police officers notified the facility that they found R1 at Campbell park. R1 was brought back to the facility around 3:45PM by police officers. The distance between the facility and Campbell Park is around 1.7 miles per google map. Co-LCN stated R1 was brought back to the facility without injury. Co-LCN stated R1 has dementia. S1 stated R1 is fine and normal after returning to the facility. Co-LCN stated R1 is unable to remember what happened about the incident. Based on the reviewed of R1's physician report dated on 11/09/2024, R1 has dementia. R1 has wandering behavior and is unable to leave facility unassisted. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. An immediate civil penalty of $500.00 is being assessed today for violation the absence of supervision. Exit interviewed was conducted with Co-LCN. The report was provided to HM for review and signature. Appeal rights was provided. A copy of the report was provide to Co-LCN.