Incident investigation·October 4, 2024

Licensing Program Analysts (LPAs Manuel Monter & Marcella Tarin conducted an unannounced case management visit continuation in regards an incident report, which stated a resident had eloped from the facility. LPAs met with Administrator Gregory Becker. LPAs explained the purpose of the visit. On August 26, 2024, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on August 20, 2024, at 12:10am, during rounds staff (referred as S12) noted that resident R1 was not in his/her bedroom in the memory unit. Staff S11 and S12 conducted a census of all memory care residents to account for the whereabouts of R1. During the rounds, the local law enforcement (LLE) arrived with resident R1, who was found outside the facility. On August 19, 2024, at about 10:16pm Local Law Enforcement (LLE) responded to resident R1 being found nearby the Apartments complex (Apex). (Based on a google maps review of the location R1 was found, R1 was .5 miles away from the facility). At around 12:30am, R1 was brought back to the facility by LLE wherein staff stated they were unsure how he/she had left the facility. Based on a review of R1’s Elopement Risk Assessment, dated July 2, 2024, R1 has a history of elopement and has wandering behaviors. Based on a review of R1’s Physicians Report, dated July 2nd, 2024, R1 has a diagnosis of neurocognitive disorder. R1 also has wandering behaviors and cannot leave the facility unassisted. Page 1 Out of 2. On August 28, 2024, and September 16, 2024, the Department interviewed 13 staff (referred as S1-S13) and Memory Care Director (MCD). 11 Out of 13 staff interviewed stated R1 has had wandering and exit seeking behaviors since he/she moved into the facility. S1 stated R1 was in his/her group, for the PM shift, the day of the elopement. S1 stated the last time he/she saw R1 was at 8:15pm on August 19, 2024. S1 stated he/she did not perform a head count of all residents assigned to him/her because he/she was busy helping other residents. Staff S12 confirmed R1 was in his/her group of residents, for the night shift on August 19, 2024. S12 stated the PM shift had informed the shift, that all the residents were in bed, but did not conduct a head count at 10:00pm. On October 4, 2024, LPA Monter and Tarin, interviewed MCD. MCD confirmed that staff need to conduct a head count of residents in the memory care unit at the beginning of their shift and end of their shift. Based on interviews, R1 was last seen by S1 at 8:15pm, on August 19, 2024. R1 was not found during head count, at 12:10am, on August 20, 2024. Based on interview, the facility staff did not preform their duties and responsibilities by not conducting a head count/welfare check for all residents in memory care between the changes in shift, PM and NOC, at 10pm to meet the care & supervision needs of the residents in memory care unit. As a result, the department issued an immediate civil penalty of $1,000 for a repeat violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Gregory Becker and a copy of the report was provided. Appeal Rights was provided. Page 2 Out of 2. END OF REPORT