Incident investigation·August 22, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today and met with Executive Director (ED) Ron Ellenich. The purpose of the case management visit was to follow up on an incident occurred on 6/26/2023 when the facility staff (S1) transported R1 to doctor's appointment and left R1 unattended in front of the doctor's clinic. R1 was found alone by R1's Power of Attorney (POA). The incident was reported to the Department via Unusual Incident Report on 7/3/2023. During today's visit, LPA Rai interviewed ED and Angel Bustos Resident Care Director (RSD). ED stated R1 resides in Memory Care Unit. ED stated S1 did admit mistake of leaving R1 unattended outside the entrance. ED stated the facility's protocol is for facility staff to stay with Memory Care residents until the resident's family meets them at the doctor's clinic/hospital. RSD stated Memory Care residents are assumed to be elopement risk and the residents need to be supervised at all times. ED admitted the facility was at fault for leaving R1 unattended outside of the entrance. During today's visit, LPA Rai reviewed written statement of S1 of the incident on 6/26/2023 which stated S1 dropped off R1 near the entrance and R1 sat down at the bench and waited for R1's POA. LPA Rai reviewed the Transportation Note for 6/26/2023 for R1 which stated R1 will be met by POA and R1 required transportation to and from the doctor's appointment. Per record review of R1's Functional Needs Assessment on 6/29/2022, R1 has a diagnosis of Dementia. Per record review of R1's care plan, R1 will receive necessary assistance with transportation. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Exit interview was conducted with Executive Director, Ron Ellenich. A copy of this report was provided to Executive Director, Ron Ellenich. Appeal Rights were provided.