Incident investigation·July 26, 2022

Licensing Program Analyst (LPA) JoAnn Rosales conducted an Case Management visit at the above facility to investigate an incident that occurred on 7/22/22. LPA met with staff Cynthia Garcia - Business Office Manager. On 7/22/22 Community Care Licensing (CCL) received an incident report from the Administrator Kortnie Spitznogle indicating that resident #1 (R1) was at a music event in the Assisted Living side and Memory Care staff was with the residents. R1 was then found by bystanders on the side of the road. Cops were called to the Community. ED/RSD ran to get R1. R1 was brought home and monitored every 2 hours that day and night. R1 was checked out by EMT. R1 was not taken to the hospital. R1's responsible person was notified. Administrator stated that staff were counciled and they have already set up retraining for 8/3/22 for all care staff. During today’s visit LPA toured the facility with staff Garcia, review resident records and obtained copies of pertinent documents. During the facility tour at 2:24 pm with staff Garcia LPA observed 2 bottles of Weber grill cleaner in back area behind kitchen door accessible to residents. During the facility tour starting at 2:26 pm with staff Garcia LPA observed dish soap, 2 bottles of windex multisurface cleaner, and spic and span antibacterial cleaner in the activity room accessible to residents. During the facility tour starting at 2:41 pm with staff Garcia LPA observed 4 shovels in the back area of the memory care unit accessible to residents. During the facility tour starting at 2:45 pm with staff Garcia LPA observed peroxide multi surface cleaner and disinfectant, asepticare aerosol-disinfectant virucide, and a lighter in the memory care unit food service station accessible to residents. During the facility tour at 3:23 pm with staff Garcia LPA observed a paper cutter in the 1st floor copy room accessible to residents. LPA reviewed R1's records starting at 3:32 pm which revealed that R1 should be escorted by staff when leaving the community. On 7/22/22 staff failed to Continued on 809C supervise R1 as R1 eloped from the facility. Interview with Resident Care Director Kelly Newcomb starting at 4:31 pm revealed that S1 was found approximately 4 blocks away from the facility. R1 did not sustain any injuries. 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.