Incident investigation·November 6, 2024

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit to follow up on an Incident Report (IR) that was received by the Department on 11/5/2024. The IR states a resident eloped from the facility on 11/1/2024. LPA met with General Manager (GM) Griselda Galvan. LPA toured the exterior and interior of the facility, which included Assisted Living (2nd floor), Memory Care (1st floor), the kitchen, office area, resident bedrooms, resident dining area, and courtyards. The facility temperature was 72 degrees F.. During tour of the Memory Care courtyard, LPA observed a gate locked in with zip ties. Staff stated the gate had a work order due to the gate alarm malfunctioning. Staff stated a work order was in place to fix the gate. During a tour of the Assisted Living courtyard, LPA observed gate #5 locked (an emergency exit). Staff unlocked the gate, and the gate key is located in the front office where staff can access in an emergency. All remaining outdoor exits were clear and free of obstruction. LPA toured 5 out of 5 resident bedrooms. Each resident bedroom has functioning lights, a bed, a chair, table/dresser and storage room for personal belongings. The following documentation was requested: resident's service plan, physician's report, resident roster, staff schedule, updated facility sketch, updated emergency disaster plan (LIC610E), and an updated fire clearance. LPA determined the above incident requires further investigation. This report was reviewed with General Manager, Griselda Galvan and a copy of the report was provided.