Incident investigation·July 29, 2022

Licensing Program Analyst (LPA) JoAnn Rosales arrived at the facility to conduct a Case Management - Incident visit and to continue the Post Licensing visit started on 4/21/22. During facility tour with staff Nicole Zanders at 11:44 am LPA observed that the facility continues to use video camera's located in the common areas inside the facility. LPA advised staff Zanders that an updated Plan of Operation and Admission Agreement needs to be submitted for licensing review and approval prior to the use of the video cameras. During facility tour with staff Zanders at 11:47 am LPA observed a sink and toilet in a storage room which is not on the facility sketch. During facility tour with staff Zanders at 11:49 am LPA observed lotion and shampoo in an unlocked resident room accessible to residents. Administrator stated that the resident that was in that room recently passed away. During facility tour with staff Zanders at 11:51 am LPA observed a wall put up in the medication room which is not on the facility sketch. During facility tour with staff Zanders at 11:52 am LPA observed isopropyl alcohol, povidone-iodine prep pads, T/Gel therapeutic shampoo, nail polish remover, triple antibiotic ointment, wound cleanser, wound & burn dressing in an unlocked cabinet in a training room accessible to residents. Staff stated that the items should have been in the locked medication room. During facility tour with staff Zanders at 12:05 pm LPA observed asepticare aerosol-disinfectant viruciden in an upstairs bathroom accessible to residents. Continued on 809C During facility tour with staff Zanders at 12:07 pm LPA observed lotion, toothpaste, deodorant, mascara, makeup, and razors in an upstairs staff bathroom accessible to residents. Staff stated that the door should have been locked. During facility tour with staff Zanders at 12:12 pm LPA observed Turf Builder weed & feed, fertilizer, and gardening tools in a backyard shed accessible to residents. LPA reviewed resident medications with staff Zanders and staff #1 (S1) starting at 1:32 pm. During a review of resident medications LPA observed that R2 did not receive their morning medications on 7/1/22 through 7/6/22 and again on 7/10/12 through 7/12/22 as S1 stated that R2 eloped from the facility. Staff Zanders stated that on 7/10/22 R2 signed out that they were leaving. Staff Zanders stated that they were not working on that day. At 3:20 pm LPA Rosales spoke with S2 who stated that R2 indicated on 7/10/12 that staff Zanders stated that it was ok for R2 to leave the facility. S2 stated that they asked R2 to sign out when they leave the facility. S2 stated that they gave R2 their morning medications before they left. S2 stated that when they returned to work the next day R2 had not returned to the facility from the prior day. S2 stated that they do not know when R2 returned to the facility. S2 stated that they were not aware that R2 was unable to leave the facility unassisted. Staff Zanders provided LPA a copy of the incident report dated 7/1/22 which indicates that on 6/30/22 sometime during the day R2 left the facility and later that day R2's family member called and told S1 that R2 was at their girlfriends house. Staff Zanders called and spoke with R2 who indicated that they wanted to stay at their girlfriend's house until after the fourth of July. Staff Zanders stated that they explained to R2 that they are not able to leave the facility unattended and R2 stated "I know". Staff Zanders asked R2 for the address so they could take R2 back to the facility and R2 refused. Staff Zanders called the Police Department to inform them that R2 eloped from the facility on 6/30/22. Staff Zanders stated that R2 did not sustain any injuries when R2 was away from the facility. On 7/13/22 Community Care Licensing (CCL) received an incident report from staff Zanders indicating that on 7/13/22 staff #1 (S1) asked staff Zanders if they had seen R1. Staff Zanders noted that they searched the facility and did not locate R1 in the facility so they ran outside and found R1 walking down the street. On 7/15/22 LPA Rosales spoke with staff Zanders regarding the 7/13/22 incident of R1. Staff stated that construction workers were going in and out of the facility and the alarms were going off alot. Staff stated that the workers are were being supervised by staff. Staff Zanders stated that S1 indicated that R1 was just there with them. Staff Zanders stated that R1 was found a house away with no injuries. Staff stated that they currently have R1 with a 1:1. Staff stated that the residents Service Coordinator is working with them to have the R1 transferred to another facility due to their change in condition. A review R1's records starting at 12:29 pm revealed that R1 is not able to leave the facility unassisted. On 7/13/22 staff failed supervise R1 as R1 eloped from the facility. A review of R2's records starting at 3:10 pm revealed that R2 is not able to leave the facility unassisted. On 6/30/22 staff failed supervise R2 as R2 eloped from the facility. On 7/10/22 R2 again left the facility unassisted. Due to time constraints LPA will need to return at a later date to continue the Post Licensing visit. 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 issued in the amounts of $250.00 and $250.00. Exit interview conducted, todays reports, civil penalties, and appeals rights were reviewed and emailed to staff Zanders.