Incident investigation·January 15, 2025

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, and met with Administrator Claudia Quijada. The case management is being conducted to review a report of a resident AWOL. The LPA reviewed the incident with the Administrator, Administrator stated the resident R1 had left the facility out the front door without staff supervision. The staff on duty didn't hear the auditory alarm on the front door, and was unaware that R1 had left the facility. A Sheriff came to the facility regarding the resident R1 which a neighbor had called due to observing the resident wandering past their home. R1 was returned to the facility after the staff identified R1 as a resident of the care home. R1 was seen by paramedics that were called when the neighbor reported the resident was wandering in the neighborhood; R1 was assessed to have no injuries from the AWOL incident. LPA obtained more information on resident incidents and death reports, including the AWOL reviewed above that were not reported to Licensing as required, per interview with the Administrator. In review of the incident, The staff failed to hear the auditory alarm on the exit door and the resident (R1) AWOL the facility without staff supervision. This deficiency will be cited, 87705 (d) Care of Persons with Dementia -The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, see LIC809D. Continued on LIC809C... Deficiency cited, 87211(a)(1)(2) Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate, see LIC809D. Deficiencies 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. Appeal rights given to the Administrator/Licensee. Exit interview conducted with Administrator/Licensee Claudia Quijada.