Incident investigation·April 9, 2024

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management - Incident visit, and met with Claudia Patricia Magana (Staff). Administrator, Pamela Johnson was not able to come, but was available by phone and gave authorization to staff to sign the report. The purpose of this Case Management Visit is to follow up on another agency report submitted to Community Care Licensing (CCL) on 4/3/24. Based on police records #SD240880063 obtained by LPA, on 3/28/24 at approximate 1:01pm, resident (R1) walked out the facility and was being aggressive to staff (S1) walking down the street and S1 was with R1 at all times. During today's visit, LPA reviewed R1's care plan and physician report dated 3/9/24 who has a diagnosis of dementia. R1's care plan indicates that R1 needs general supervision due to confusion and wandering. Based on interviews with staff (S1), it was confirmed that they were following R1 at all times to ensure their safety while they were wandering away of the facility. Per Administrator, they were in the facility and attempted to re-direct R1, but R1 wanted to keep walking away from the facility, so they had S1 following them around. However, the facility did not notify CCL regarding the incident. LPA had a discussion with Administrator clarifying when an incident report needs to be submitted to CCL. 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. Exit interview conducted with staff and a copy of this report was printed for the facility.