Incident investigation·September 9, 2021

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 8/26/21. LPA met with Eric Terrill - Administrator. On 9/2/21 LPA spoke with staff Ashley Phelps regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 8/26/21. R1 was observed approximately 2 blocks from the facility and was redirected by staff back to the facility. R1 did not sustain any injuries. R1's primary care provider and family member were notified of the incident. Staff stated that based on R1's physicians report R1 is not able to leave the facility unassisted. LPA reviewed R1's records on 9/7/21 which revealed that R1 is not able to leave the facility unassisted. During today’s visit LPA toured the facility with staff Ashley Phelps. During facility tour starting at 10:41 am with staff Phelps LPA observed lysol disinfecting wipes, bleach, disinfectant cleaner, laundry detergent, fabric softener, oxi clean stain remover, lime-a-away cleaner, toilet bowl cleaner, and furniture polish in an unlocked housekeeping room accessible to residents. Interview with Administrator at 3:28 pm revealed that R1 will be provided with 1:1 caregiving services until they are able to move R1 to the Gardens (Memory Care). Administrator stated that R1 is scheduled to move to the Gardens on 9/13/21. Based on information obtained during the investigation staff failed to supervise R1 on 8/26/21 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, todays reports were reviewed and emailed to the Administrator.