Incident investigation·August 17, 2023

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Carewell at Pistachio LLC for the purpose of conducting a Case Management- Incident inspection. LPA was granted access to the facility by carestaff. LPA spoke with Administrator via phone. Department learned via a Special Incident Report (SIR) that on 07/16/2023 resident (R1) left the facility unassisted at 04:16 PM and was found by Local Law Enforcement nearby at 4:45 PM and returned to the facility unharmed. Resident's physician's report dated on 06/23/2022 states that resident has a diagnosis of dementia and not allowed to leave facility unassisted. Resident had been at the facility for one year with no history of wandering. LPA discussed re-training staff regarding wandering behaviors and safe practices for caring for residents with Dementia with Administrator. Administrator agreed to conduct a review with staff. No citations were issued. Exit interview conducted with care staff, Sonia Jones.