Incident investigation·June 14, 2022

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on 2 (two) self-reported incident reports. Upon arrival, LPA was informed Executive Director Martha Berard was unavailable. LPA met with Business Office Director Kailey Vanderwall and explained the reason for today's visit. On 06/13/2022, the Woodland Hills Adult and Senior Care Regional Office (RO) received 2 (two) written incident reports via fax. One incident occurred on 06/05/2022 and involved Resident #1 (R1) eloping from the facility's secure Memory Care unit. The second incident also involved R1 eloping from the facility's Memory Care unit on 06/07/2022. During today's visit, LPA toured the facility with Business Office Director at 11:40AM, during which all interior delayed egress doors were tested, interviewed staff at 12:08PM, 01:19PM and 02:40PM and tested the exterior delayed egress at 01:15PM. All interior delayed egress alarms were functional at the time of the visit. One exterior gate with delayed egress leading from the Memory Care patio to the Assisted Living courtyard was observed to be bolted shut at 01:14PM. Staff interview revealed that about a month ago, the delayed egress on that gate was not functioning properly and at that time, maintenance bolted the gate shut. Record review revealed that R1 moved into the facility on 05/11/2022, has a history of wandering behavior, and is unable to leave the facility unassisted. Interview confirmed that R1 is known to be an elopement risk and when R1 is kept busy with activities, R1 is less likely to engage in wandering behavior. Staff interviewed stated they are unsure how R1 was able to exit the facility without an alarm sounding. Delayed egress is tested daily and staff reported it has been functional during all tests, as well as during today's visit. Staff stated it is possible R1 pushed the keypad code, disarming the system, and exited the door. Following the second elopement incident, the code was changed and R1 was given a Wanderguard bracelet. Report Continued on LIC 809-C Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Civil penalties assessed in the amount of $500.00. Exit interview conducted. Todays reports, appeal rights and civil penalties were reviewed with Business Office Director and emailed to the Administrator.