Incident investigation·July 8, 2022

Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 06/29/2022. LPA met with Executive Director (ED) Martha Berard and explained the reason for today's visit. On 06/29/2022, LPA Dulek received a text message from Martha Berard indicating the Health Services Director (HSD) would be calling the LPA due to an incident that had occurred at the facility where Resident #1 (R1) eloped from the facility’s secure memory care unit. LPA received a phone call and voicemail from Health Services Director. Written report was faxed the same day, however, was not received in the Woodland Hills Regional Office (RO). A copy of the written report was obtained during today’s visit. Previously, R1 had similar reported incidents on 06/05/2022 and 06/07/2022. At that time, the door code was changed, R1 was given a Wanderguard bracelet, all delayed egress exit points were tested for functionality, and a resident reassessment was completed. During today’s visit, LPA interviewed HSD at 04:10PM, LPA reviewed the staff schedule and compared to payroll records, and a tour of the secure memory care unit was conducted with ED Berard at 04:40PM. All delayed egress exit points were tested and functional during today’s visit. HSD indicated there was a care plan meeting with R1’s family today, R1’s physician adjusted R1’s medication and the memory care activity schedule was adjusted. HSD indicated all staff have reviewed the facility’s elopement procedure. 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 $250.00. Exit interview conducted. Today’s reports, appeal rights and civil penalties were reviewed and provided via email.