Incident investigation·October 14, 2024

Licensing Program Analysts (LPAs), Valeria Conway and Kelly Dulek, conducted an unannounced Case Management – Incident visit. The purpose of the visit is to investigate self-reported incident report submitted to the Department on 10/07/2024. Upon arrival, LPAs met with front desk staff. Administrator, Monica Reyes, was called via phone. At 11:35 a.m., Administrator arrived at the facility. Reason for the visit was explained. Entrance interview. The Incident report submitted noted that on 10/06/2024 at 1:30 p.m., a staff member noticed Resident #1 (R1) walking in the Memory Care (MC) garden area. Per incident report, “R1 was doing activities and they had just seen him walk in, and then after five (5) minutes they (staff members) looked again and R1 was no longer there”. Staff members then called the Administrator and the Sheriff Department. At 1:45 p.m., R1 was found across the street walking around the park. On 10/10/2024, LPA Conway, conducted a phone interview with facility Administrator Monica Reyes between 10:35 a.m. and 10:47 a.m. During the interview Administrator stated that Resident 1 (R1) have been triggering the emergency alarms frequently since R1 was admitted on 10/04/2024. Administrator confirmed that R1 eloped from the facility by jumping a fence surrounding the Memory Care (MC) garden. No injuries were reported, and family members were informed. Continued on LIC 809-C Continued from LIC 809-C During today's visit the LPAs conducted a tour of the Memory Care unit at 12:30 p.m. LPAs interviewed Administrator and random staff members between 10:30 a.m. and 2:30 p.m. LPAs also reviewed facility records and obtained pertinent copies. During the record review, LPA Conway reviewed the pre-admission appraisal for R1, physician’s report, dated on 09/24/2024, and the Care Assessment and Service Plan. Documentation indicates that R1 is confused/disoriented and has wandering behavior confirming the resident’s tendency to wander. According to the Administrator, following R1’s elopement, staff are providing close supervision while the resident is in the garden. Furthermore, administrator’s recommendation to R1’s responsible party is to hire a private caregiver to help prevent R1 from leaving the facility. LPA’s attempted to interview R1, however R1 was unable to communicate in English. LPA’s asked Administrator to demonstrate that the delay egress side gates were functioning properly during the visit. Between 1:10 p.m. - 1:15 p.m. both gates were tested, and the alarm was triggered when the bars were pushed. Pursuant to Title 22 of the CA Code of Regulations and Health and Safety Code, the following deficiencies were cited (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.