Incident investigation·August 14, 2024

Licensing Program Analysts (LPAs) David Marrufo and Santino Fortes conducted an unannounced Case Management visit and met with Audie Ton-Od, Memory Care Supervisor . The purpose of the visit was to respond to an incident report that the facility submitted to the Department on 8/12/24. The incident report stated that on 8/12/24 memory care resident R1 left the facility unassisted. A neighbor found the resident and called the facility at 2:35PM. At 2:50pm, facility staff found the resident in the neighboring community and paramedics took the resident to the hospital. R1 was observed to have scrapes to the left arm and left forehead with minimal bleeding. R1's Physician Report states that R1 has dementia and is not allowed to leave the facility unassisted. During visit, LPAs interviewed staff S1 and S2. S1 stated that it is still unknown how R1 left the facility unassisted. S2 stated to have observed R1 in the facility hallway around 2:15 PM, but did not observe R1 leave the facility. During visit, LPAs tested 4 out of 4 Memory Care exit doors and all 4 doors had functioning alarms. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with Audie Ton-Od, Memory Care Supervisor, and a copy of this report and the appeal rights were provided.