Incident investigation·February 1, 2024

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conducted an unannounced case management and met with Administrator, Mary McClure. The purpose of this case management inspection is to follow up on two self-reported incident reports submitted to Community Care Licensing (CCL). CCL received the first self-reported incident report form on 10/25/2023 reporting on 10/20/2023 at approximately 1:35 pm resident (R1) had eloped from community. Facility staff conducted search and located R1 at a local park at approximately 3:10 pm. Report states garden latch was not locked by gardeners who obtained key from staff to conduct work, when elopement occurred. No visible signs of injury noted by resident care director (RCD) and R1 denied any pain. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. Interview with RCD informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 10/20/2023. LPA also followed up on a second incident submitted to CCL on 12/19/2023 of an attempted suicide on 12/18/2023 where R2 was sent out to emergency room. Resident is being placed in different placement from discharge from hospital. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) 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 and appeal of rights provided