Incident investigation·October 18, 2023

Licensing Program Analysts (LPAs) Teresa Camara and Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on three (3) self-reported incidents that occurred on 09/18/2023, 10/01/2023, and 10/11/2023. LPAs met with Executive Director Bradlee Foerschner. LPAs explained the reason for today's visit. Previously, on 09/19/2023 an Unusual Incident/Injury Report was received via e-fax at the Woodland Hills Regional Office. LPA reviewed the document, which indicates that Resident #1 (R1) left the community unsupervised and was found a block away. R1 resides in Assisted Living, however has a dementia diagnosis and is unable to leave the facility unassisted. On 09/22/2023, LPA conducted an initial case management - incident visit related to R1 leaving the community unsupervised. During that visit, LPA Dulek, along with Business Office Director toured the facility at 08:52AM, interviewed staff between 09:33AM to 10:30AM as well as at 12:31PM, and LPA obtained copies of pertinent documents. Additionally, LPA, along with Health Services Director and Business Office Director tested the Wanderguard alert beginning at 11:11AM, and LPA interviewed residents from 11:44AM to 12:13PM. On 10/02/2023, ED had called and left a voicemail message for the LPA indicating Resident #2 (R2) who resides in Traditions had been found outside about a block away from the facility on 10/01/2023. R2 does have a diagnosis of dementia and is unable to leave the facility unassisted. During a case management - incident visit conducted on 10/05/2023, LPA interviewed ED related to this incident as well as the previous incident involving R1, LPA along with ED toured the facility at 12:45PM, all delayed egress points were tested, and LPA obtained copies of documents pertinent to the incident. On 10/12/2023, LPA Dulek received a telephone call from ED indicating that on 10/11/2023 around 03:00PM, R2 was found outside the facility and had fallen in front of a neighboring home. Report Continued on LIC 809-C During today's visit, both LPAs conducted interviews with staff and residents from 01:29PM to 02:40PM. LPAs obtained a copy of written incident report for the 10/01/2023 incident. ED indicated that following the latest incident, R2 has been given a Wanderguard bracelet for additional safety. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Executive Director was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.