Incident investigation·July 29, 2022

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced CASE MANAGEMENT- INCIDENT visit to the above facility to investigate an incident that occurred on 7/17/2022. LPA met with Executive Director (ED), Sarah Dodd. Entrance interview conducted. On 7/22/2022, LPA Arroyo spoke with the ED regarding an incident of Elopement for Resident #1 (R1). on 7/17/2022. It was reported that on 7/17/2022 at 7:30 p.m., R1 entered the elevator in the memory care unit along with a private companion of another resident. R1 then proceeded to follow the private companion out of the elevator and exited the facility. Interviews revealed that although there is a front desk clerk every day between the hours of 8am to 8pm, R1 was still able to walk out of the facility unnoticed. Around 8:20 p.m., a staff member noticed R1 wandering in the parking lot and walked them back into the facility. The LPA confirmed with R1's family member that the facility reported the incident the following day after the incident had ocurred. A review of R1's records revealed that per R1’s Physician’s Report dated 6/19/2022, R1 is not able to leave the facility unassisted. However, R1 was found outside of the facility alone and unassisted by facility staff. ED provided LPA with documentation showing the memory care staffs have been in-serviced training regarding safety and elopement protocols. Based on the information obtained during the investigation staff failed to supervise R1 on 7/17/2022 as R1 eloped from the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Appeal Rights discussed. Today’s reports were reviewed and emailed to the Executive Director.