Incident investigation·March 28, 2023

Licensing Program Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to conduct a case management – incident visit. LPAs met with Executive Director (ED), San Sor, Memory Care Director (MCD) Sherry Theam, and Health Service Director (HSD) Paula Spanek. The purpose of the visit was to follow-up on an elopement incident on 02/18/2023 for resident (R1). Based on record review, R1 is diagnosed with a neurocognitive impairment and is unable to leave the facility unassisted. On 02/18/2023, R1 was noted missing around midnight when the wander guard alarm went off in the Memory Care unit. A few minutes later, R1 was found on the sidewalk outside of the community near the apartment complex. 911 was called to the scene to assess for possible injuries. No injuries were noted, and resident denied pain/discomfort. R1 was brought back to the community the same night. During visit, LPAs toured the memory care unit. LPAs observed exit areas and tested the exit doorways. LPAs interviewed ED and MCD regarding the incident and plan of action after the incident. Based on record review, on 02/20/2023, in-service training was done with all staff to include topics on emergency situations and elopement drill. On 02/21/2023, a care meeting was scheduled with R1’s responsible party to discuss recommendations for R1's safety going forward. LPAs observed R1's needs and services plan which addressed R1's wandering behavior and updated physician's report. LPAs obtained R1's progress notes and facility correspondence. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with ED, MCD, and HSD and a copy of this report was provided.