Incident investigation·April 2, 2025

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Yuly Arita, Office Manager (OM). The purpose of the visit was to follow up on an incident reported by the facility via Unusual Injury/Incident Report (IR) on 03/21/2025. The IR states that on 03/21/2025 at approximately 3:00 PM, resident R1 left the facility via taxi to go to the post office. The IR states that staff attempted to bring R1 back into the facility, but R1 entered the taxi and left. Staff found R1 at a local post office and returned R1 to the facility at approximately 3:20 PM. During visit, LPA Marrufo interviewed OM, who stated that R1 left the facility through the front patio door. OM stated that OM normally takes R1 to the post office, but on the day of the incident, OM was busy and was not able to take R1 to the post office. OM stated R1 called the taxi service. OM stated when the taxi service arrived, staff let the taxi driver know that R1 is unable to leave the facility, but the taxi driver took R1 anyway. OM stated the facility has previously contacted the taxi company and informed them that R1 is not able to leave the facility unassisted. OM stated to have assessed R1 upon his/her return to the facility and determined R1 was fine. During visit, LPA discussed with OM about reminding R1 to not leave to the post office alone and to wait for a staff to take him/her to the post office. R1's Physician's Report states R1 has dementia and is unable to leave the facility unassisted. R1's Physician's Report states R1 has wandering and sundowning behavior. R1's Appraisal/Needs and Services Plan states R1 has been trying to leave the facility. See LIC809-C page for more information. Page 1 of 2. During visit, LPA Marrufo conducted a health and wellness check with R1. LPA observed that the front patio door alarm was triggered when the door was opened. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with OM Yuly Arita and a copy of this report and appeal rights were provided.