Incident investigation·July 28, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – incident visit. LPA met with Executive Director (ED) Jolie Higgins and Resident Service Director (RSD) Ria Hernandez. On 07/24/2023, the Department received an incident report for resident (R1) reporting R1 had eloped from the facility on 07/22/2023. On 07/22/2023 at 11:20am staff noticed resident was missing when residents were being called for lunch. R1 was last seen at 11:10am. Staff checked all rooms, did a head count, and immediately went out of the community to look for R1. Within 10 minutes, R1 was found in close proximity from the facility. R1 was brought back to the community and re-assessed. The Fire Department was contacted to evaluate resident and no change of condition was found. Family was notified. During the facility’s investigation, it was found that one of the egress doors did not reset after the facility was experiencing several power outages from 07/21/23 – 07/22/23. Based on interview with the ED, 4 out of 5 delayed egress doors were checked after the power outage on 07/21/23 - 07/22/23. 1 out of 5 doors was missed during the checks, which was the door R1 had exited from. Based on record review, R1 is not able to leave the facility unassisted. After the incident, the facility immediately updated R1’s care plan and placed R1 on alert charting. The facility completed an in-service training with staff on Egress doors and Elopement. Going forward the facility plans to designate a staff to ensure all egress doors are functioning properly after an outage. During visit, LPA toured the memory care section with ED, RSD, and Maintenance Director (MD). 5 out of 5 egress doors were tested in Memory Care. 4 out of 5 egress doors observed working. 1 out of 5 egress doors not observed working and would not open. This is the same door R1 had exited from. Based on interview, the doors were checked on 07/22/23 – 07/24/23 and observed in working condition. LPA observed the facility's egress door after a couple hours. LPA observed the door was able to open after inputting a code. The facility is currently in contact with the vendor to fix the sound system for the egress door. A deficiency was cited per California Code of Regulations, Title 22. This report was reviewed with Executive Director (ED) Jolie Higgins and Resident Service Director (RSD) Ria Hernandez and a copy of the report was emailed to ED and RSD due to technical difficulties.