Incident investigation·May 24, 2024

On 05/24/24, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannouncied to conduct a Case Management regarding an incident that occurred on 05/15/2024. LPA Campbell met with Melina Nunez, Assisted Living Director and explained the purpose of the visit. On 05/15/24, the facility self-reported an incident regarding a resident (R1) who left the facility unassisted. Per R1's 602, they were not to leave the facility unassisted and were prone to wandering behavior. A neighbor saw R1 walking unassisted about 8 minutes away from the facility and notified facility staff. Staff 1 (S1) returned R1 to the facility and a medical evaluation was conducted by S2 for R1. The incident report was submitted to the Department the next day on 05/16/2024. Per the Assisted Living Director, R1 was able to leave the facility because staff did not conduct a head count for Wander guard residents after the alarm signaled. Wander guard will alert if a resident is wearing one near the entrance. R1 was wearing a Wander guard. At the time of R1's elopement, there were several residents wearing Wander guard near the entrance. The residents were at the same entrance that R1 used to leave the facility and there was an alert. No staff verified the presence of all the Wander guard residents in the facility. Instead, staff assumed no residents had actually left the facility and were just at the entrance. The facility was unable to recount when R1 left the facility or for how long. R1's family was notified of the incident. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed.  A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.