Incident investigation·May 15, 2023

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Li Li. The Case Management visit was in response to an incident involving resident R1 leaving the facility without supervision on 03/22/2023 and reported by the facility via Unusual Injury/Incident Report on 03/24/2023. During visit, LPA Marrufo obtained copies of R1's records and staff records. R1's Physician's Report states R1 has dementia and is unable to leave the facility unassisted. R1's updated Resident Assessment states that R1 is to be escorted to all meals and staff are to conduct nightly checks. The facility assignment log for PM shift states orders to conduct safety checks every 2 hours. The assignment log for Noc Shift includes orders to conduct safety checks on R1 at 1 AM, 3 AM, and 6 AM. LPA Marrufo obtained a copy of the In-Service Elopement training that was conducted on 04/05/2023. LPA Marrufo interviewed staff S1-S3, who stated that they conduct safety checks on R1 every 2 hours and escort R1 to breakfast and lunch. An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Li Li and a copy of the report was provided.