Incident investigation·August 9, 2023

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced subsequent Case Management - Incident visit to the above facility. The purpose of the visit is to conclude an investigation initiated by LPA during a Case Management- Incident visit conducted on 07/20/2023. The LPA met with Family Advisor Ashley Villarreal and the reason for the visit was explained. On 07/20/2023, the Department received an Unusual/Serious Incident Report (SIR) reflecting that on 7/20/2023, Resident #1 had eloped from the facility at approximately 1:00 p.m. It was reported that R1 was outside of a nearby I-Hop restaurant when the facility received a call from Housekeeping Staff (S1), who was off the clock and having lunch informing staff that R1 had eloped from the facility and was with them. Upon receiving the information, staff picked up and returned R1 back to the facility. Information gathered during the initial visit reflected that per R1’s Physicians Report (LIC602) dated 12/14/2018, R1 does not have a diagnosis of dementia and is able to leave the facility unassisted, with their next of kin being notified. However, based on interviews conducted staff voiced concerns regarding R1 leaving the facility unassisted and being unable to find R1’s way back to the facility. A review of R1’s nursing notes reflected that changes in condition were not being documented. Interviews conducted and documents reviewed reflected that even though staff observed R1 to have a change in condition, facility staff did not documented in R1’s reappraisal, or notify R1s Primary Care Physician (PCP) of these concerns. Report will continue on LIC809-C On 08/02/2023, the Department received a second SIR. It was reported that on 07/31/2023, at approximately at 11:55 a.m., the facility received a call from a bystander who found Resident #2 (R2) at 5740 Ralston Street and noticed R2 seemed lost and out of place. Upon receiving the information, staff picked up and returned R2 back to the facility. It was identified that R2 exited the facility through the main entrance for approximately one (1) hour prior to being located on the street. R2 was provided basic first aid for a small scrape on R2s left knuckle, and a small scrape on R2s right pinky toe. Per R2’s Physician Report dated 8/16/2022, R2 has a diagnosis of dementia and cannot leave the facility unassisted. Information gathered reflected that front desk staff were on break during the time of R2’s elopement and staff were not aware that R2 exited the facility. During today’s visit, the LPA, Family Advisor Ashley and Wellness Director Justin discussed both incidents, Ashley stated that the two employees who previously were at the front desk have been moved to different job duties. Ashley also stated that to ensure no further elopements to occur, the Administrator is looking at different security systems to put in place, additional training for staff, and that the list at the front desk of residents who cannot leave without assistance is continuously being updated. 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, today's reports and appeal rights were reviewed and issued to Wellness Director Justin Ramirez.