complaint·November 12, 2021

Continued from 9099 Based on interviews, record reviewed, police reports LPA learned that on 5/19/21, residents (R1) and (R2) eloped from the facilities memory care secured perimeter. Statements from interviews reveal residents were missing for approximately 30 minutes. Staff were alerted by the Vacaville Police Department that both residents were found in the back of the building, and resident R1 had been injured. The police and resident’s medical records indicate that R1 had sustained significant injury and was transported to the emergency room. R2 was returned to the facility. Responsible parties were notified. R1 subsequently declined and passed away 16 days after the incident occurred. Coroner’s report identified the injury R1 sustained on 05/26/2021 as cause of death. During interviews, with Office Coordinator and 5 of 5 staff interviewed report not hearing delayed egress alarm alerting them that R1 and R2 eloped. Facility’s staff checklist and interviews confirm that medication technician’s are to check door alarms every shift. It was reported during interviews and through record review that the alarm was operational two hours before the residents eloped. Statements from interviews reveal that both residents exited through a delayed egress, which was not operational. Based on statements received, Vacaville Police Department records, resident records and R1’s medical records the allegations are substantiated. The Department has determined that the allegations that resident R1 sustained injuries due to staff neglect and Neglect and lack of supervision resulted in residents R1 and R2 wandering from facility are Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Continued on 9099 C Continued on 9099 C An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.