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25 | Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit in regards to an incident report the department received on July 23, 2024. LPA met with Administrator (ADM) Anabelle Ablan and explained the purpose of the visit. (This Report is being amended to issue a civil penalty and deficiency that was inadvertently not issued during the case management visit.)
On July 23, 2024, the department received an incident report stating the resident R1 had eloped from the facility. The incident report stated the following; resident R1, who has a neurocognitive disorder, left the facility without staff noticing. R1 was found 3 houses away from the park sitting on one of the benches. The Incident Report states the incident took place on July 19, 2024, at approximately between 6am to 6:30am. The incident report also states the facility staff noted that R1 was not found in his/her bedroom and the sliding door in his/her room was open and the door alarm was turned off.
On July 23, 2024, LPA Manuel Monter arrived at the facility and rang the door bell at 3:15pm. LPA observed thru the front door's decorative glass that staff S1 was moving a table that was placed in front of the door. LPA also heard the staff S1 moving the table from the front door. LPA asked S1, why the table was in front of the front door. S1 stated it was because R1 had recently left the facility and R1 is trying to leave the facility. (Photographs were taken)
LPA went to observe resident R1's bedroom, (bedroom #5). LPA observed staff S1 removing a stick from the bottom portion of the sliding screen door for bedroom #5 (Resident R1's bedroom). S1 stated this was done because R1 was trying to leave the facility. LPA asked S1 to open the bedroom #5's sliding screen door. When S1 opened the door, the door alarm did not ring. LPA also observed one of the facility's living room couch inside bedroom #5. Staff S1, S2 and ADM stated the couch was placed directly in front of bedroom #5's sliding screen door, was to prevent R1 from eloping. Staff S2 stated it was the ADM's idea on how to prevent R1 from leaving the facility. (Photographs were taken). Page 1 Out of 2. |
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32 | LPA toured resident bedroom #4 with ADM. Resident bedroom #4's sliding door alarm was turned off. Staff S2 stated R1 has attempted to leave the facility by going thru bedroom #4. ADM stated R1 has attempted to enter resident bedroom #4.
LPA toured resident bedroom #3 with ADM. Resident bedroom #3's sliding door alarm was turned off.
LPA toured resident bedroom #2 with ADM. Resident bedroom #2's sliding door alarm was turned off.
LPA asked ADM why the front door was blocked with the table. ADM stated they put it there because "she doesn't know what to do any more, and know its a violation." ADM stated R1 also tries to get out of the facility through the front door.
LPA reviewed R1's physician's report, dated June 10, 2024, which states that R1 has a neurocognitive disorder. The physicians report also states R1 is confused/disoriented and has wandering behavior. R1 also cannot leave the facility unassisted.
Based on a review of R1's preplacement appraisal (LIC603) and Resident Appraisal (LIC603A), dated May 18, 2024, R1 "needs special observation/night supervision(due to confusion, forgetfulness, wandering).
Based on record Review, R1's Appraisal/Needs and Services Plan (LIC625), dated May 18, 2024 does not address resident R1's wandering behavior.
LPA requested to review facility staff training records, regarding dementia. ADM stated she left the training records back at her home and they were not available at thee facility.
An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility.
Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Anabelle Ablan. Appeal rights were provided.
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END OF REPORT. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/24/2024
Section Cited
CCR
87468.1(a)(2)
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7 | 87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This Requirement was not met as evidenced by: | 1
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7 | ADM stated she will send LPA a plan of action on how she will ensure she is providing a safe and healthful accommodations for R1. ADM stated she will send the plan of correction by POC date, July 24, 2024. |
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14 | Based on interviews and observation, Resident R1's bedroom sliding door was blocked with a couch and a stick. ADM, S1 and S2 stated this was done to prevent R1 from exiting his/her bedroom. This poses/posed an immediate health, safety or personal rights risk to persons in care. | 8
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Type A
07/24/2024
Section Cited
CCR87307(d)(6)
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7 | 87307 Personal Accommodations and Services (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This Requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a plan of action on how she will ensure All outdoor and indoor passageways and stairways shall be kept free of obstruction. ADM stated she will send the plan of correction by POC date, July 24, 2024. |
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14 | Based on interviews and observation, Resident R1's bedroom had a couch obstructing the exit outside. ADM, S1 and S2 admitted they obstructed R1's sliding screen door and the front door of the facility due to R1's exit seeking behaviors. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/24/2024
Section Cited
CCR
87705(j)
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7 | 87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This Requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a plan of action on how she will ensure all exits have an auditory device, turned on, to protect the health and safety of residents with exit seeking behaviors |
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14 | Based on observation, Resident bedrooms 2-5's sliding doors alarms were turned off. Based on record review, resident R1 cannot leave the facility unassisted and he/she has exit seeking behavior. This poses/posed an immediate health, safety or personal rights risk to persons in care. | 8
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14 | ADM stated she will send the plan of action by POC date, July 24, 2024. |
Type A
07/24/2024
Section Cited
CCR87705(k)(7)
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7 | 87705 Care of Persons with Dementia (k)(7) For each incident in which a resident wanders away from the facility unsupervised...The report shall be made by telephone no later than the next working day and in writing within seven calendar days. This Requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, July 24, 2024. |
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14 | Based on interview with ADM, the ADM admitted that she did not contact community care licensing to make a report the next working day. ADM stated she did not know she had to call in to make a report. This poses/posed an immediate health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/24/2024
Section Cited
CCR
87405(d)(2)
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7 | 87405 Administrator - Qualifications and Duties (d)(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
This Requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a letter of understanding regrading the regulation. ADM stated she will send the letter by POC date, July 24, 2024. |
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14 | Based on records reviewed and interviews conducted, Administrator did not exhibit the knowledge of applicable laws, rules and regulations resulting in serious violations involving a resident who eloped from facility which poses an immediate health safety and personal rights risk to persons in care. | 8
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Type A
07/24/2024
Section Cited
CCR87463(a)
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7 | 87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary...shall document changes in the resident's physical, medical, mental, and social condition...
This requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a plan of action on how she will ensure residents needs and services plans are updated in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. ADM stated she will send LPA a copy of R1's updated Needs and Services plan. |
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14 | Based on document review and investigation, R1's needs and services plan was not updated after R1 had eloped from the facility. The facility did not update the care plan for R1 to meet his/her needs. This poses an immediate risk to the health of the resident. | 8
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14 | ADM stated she will send the written plan of action to LPA by POC date, July 24, 2024. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/02/2024
Section Cited
CCR
87468.2(a)(4)
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(4) To care, supervision, and services that meet their individual needs ... by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by; | 1
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7 | ADM stated she will conduct training for her staff regarding wandering residents and elopement. ADM stated she will send documentation of training to LPA by POC date, August 2, 2024. |
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14 | Based on interviews conducted, resident R1 had elopped from the facility on July 19, 2024 and staff did not provide R1 with Care and Supervision to met his/her needs. This poses an immideate threat to health, safety or personal rights risk to persons in care. | 8
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Type B
08/02/2024
Section Cited
CCR87412(f)
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7 | 87412 (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying... This requirement was not met as evidenced by;
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7 | ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, July 26, 2024. |
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14 | Based on interview conducted, LPA requested to review staff dementia training records. ADM stated the records were at her home and unavailable for LPA to inspect. This poses/posed a potential health, safety or personal rights risk to persons in care. | 8
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14 | ADM stated she will send staff dementia training records for 2023 & 2024, to LPA by POC date. |