Incident investigation·May 24, 2024

Licensing Program Analyst (LPA) Julie Florio arrived unannounced at facility to conduct a case management and was greeted by caregivers, Julieta D. De Jesus and Joy Awa . Caregivers attempted to reach Licensee/Administrator via phone. Caregiver, Dinah Belandres arrived at 9:45 AM and was able to reach Licensee/Administrator via phone at 9:50. LPA spoke with Licensee/Administrator, informed Licensee/Administrator the purpose of the visit is to follow up on an a self-reported incident report of resident (R1) elopement submitted to Community Care Licensing (CCL) on 5/16/2024. Licensee/Administrator gave verbal authorization for LPA to proceed with the visit and Licensee/Administrator would arrive to facility as soon as possible. CCL received a self-reported incident report that occurred at approximately 8:45 AM on the morning of 5/15/2024. It was reported at approximately 8:55 PM on the evening of 5/16/2024 by Licensee/Administrator that R1 told the caregivers that he wanted to go for a walk around the backyard as he does this every morning for about 30 minutes. Licensee/Administrator reported that when caregivers checked on him, they didn't find him and observed the backyard gate to the front of the house was open. Licensee/Administrator reported that caregivers looked for him for approximately 30 minutes and notified Licensee/Administrator who then called 911. Licensee/Adminstrator reports that the local police found R1 on the next block and reported that R1 claimed to have stumbled on a small rock which caused him to fall and he complained of shoulder pain. Licensee/Adminstrator reported that R1 was then taken to Kaiser Vacaville Emergency Room and R1's signficant other was contacted Per R1's Physician’s Report (LIC602) dated 04/24/2024, R1 has dementia and is unable to leave facility unassisted. LPA reviewed R1's Appraisal/Needs and Service Plan (LIC625) and noted that it needs to be updated to include increased supervision of R1 throughout the day and that he is not to be in the backyard or outside of the facility without supervision. Facility is being cited for not providing the services necessary to meet resident needs as evidenced by a lack of supervision while in the backyard which led to elopement and injury (see LIC809-D). Continued on LIC809-C... Continued from LIC809... During visit, LPA interviewed R1 who expressed a desire for more interaction and would like daily activities to occur in facility. LPA did not witness any activities happening during visit, and upon reviewing the activities schedule, determined that it does not truthfully and accurately reflect daily activities that occur in the facility. LPA advised Licensee/Administrator and staff of more appropriate, realistic, and achievable daily activities that take the needs of the residents in care into consideration. LPA is requesting an updated activities schedule and proof they are occurring as scheduled (see LIC809-D, Plan of Correction). A copy of the following documents were requested for facility file and are to be submitted to CCL within 10 days of this visit: R1s Hospital Discharge Instructions and Documents The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee/Administrator and appeal of rights provided. Signature on form confirms receipt.