Incident investigation·October 28, 2021

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 10/17/21. LPA met with Administrator Nickie Perez. On 10/20/21 LPA spoke with the Administrator regarding an incident report received for resident #1 (R1) indicating that R1 eloped from the facility on 10/17/21. R1 was half a block away from the facility and was in someone else's home. Staff picked up R1 and they returned to the facility. R1 did not sustain any injuries. R1's primary care provider 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 the Administrator and reviewed resident records. A review of R1's records at 12:20 pm revealed that R1 is not able to leave the facility unassisted. During facility tour at 11:15 am with the Administrator LPA observed body wash in Building #2's shower room accessible to residents. During facility tour at 11:19 am with the Administrator LPA observed Zinc Oxide ointment and perineum wash in R2's bedroom in Building #2 accessible to residents. During facility tour at 11:21 am with the Administrator LPA observed body lotion in Building #2's front desk accessible to residents. During facility tour at 11:24 am with the Administrator LPA observed stainless steel cleaner, dish detergent, grill and oven cleaner and 2 scissors in the kitchen in Building #1 accessible to residents. During facility tour at 11:28 am with the Administrator LPA observed air freshener, shaving cream, a razor, shampoo and body wash in a restroom in Building #1 accessible to residents. Continued on 809C During facility tour at 11:31 am with the Administrator LPA observed foam hair mousse, perineum wash, shampoo and body wash in a restroom in Building #2 accessible to residents. Interview with Administrator at 1:00 pm revealed that they will be conducting staff training today regarding safety and elopement protocols. Administrator stated that they also have additional staffing and provided an updated copy of their LIC500 Personnel Report. Administrator stated that they are in the process of getting delayed egress. Administrator stated that they have spoken with the Fire Inspector and will also submit the request to Community Care Licensing. Based on the information obtained during the investigation staff failed to supervise R1 on 10/17/21 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.