Incident investigation·January 27, 2022

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 1/23/22. LPA met with Eric Terrill - Administrator. On 1/24/22 LPA spoke with the Administrator regarding an incident of Elopement for resident #1 (R1) on 1/23/22. R1 was missing for approximately 3 hours. Facility staff searched the immediate and surrounding areas and called the Sheriff's department. Administrator stated that they called in additional staff to help with the search. R1 was found at a home located next door to the facility sitting in an unlocked car. R1 was taken back to the facility by the Administrator . R1 did not sustain any injuries. R1's physician and family member were notified of the incident. Administrator stated that based on R1's physicians report R1 is not able to leave the facility unassisted. During today’s visit LPA toured the facility with staff Naomi Hernandez and the Administrator. LPA conducted interviews with random staff and R1. A review of R1's records starting at 12:35 pm revealed that R1 is not able to leave the facility unassisted. Administrator stated that they conducted interviews with staff working at the time of the incident who indicated that they are not aware of how R1 left the facility. Administrator stated that the door alarms were functioning properly. Based on information obtained during the investigation staff failed to supervise R1 on 1/23/22 as R1 eloped from the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted, todays reports were reviewed and emailed to the Administrator.