Facility Evaluation Report

This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 02/10/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

The incident report states that on 02/08/23, R1 withdrew all of their personal and incidental funds, took their morning medications, and went to their room, but that later during room checks facility staff noticed R1 was not present at the facility. Facility staff reported R1 missing to the Garden Grove Police Department (GGPD), R1’s responsible party, and R1’s doctor.

During today’s inspection, LPA reviewed R1’s resident file and interviewed AD. LPA reviewed R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) LIC602A dated 02/01/23 which states that R1 is able to leave the facility unassisted and that R1 does not have any memory care diagnoses. AD stated that this is the second time R1 has left the facility and that R1 previously left on 10/27/22, was the subject of a missing persons report, was missing for approximately one month, was found and hospitalized, stabilized, and returned to the facility, and had been back at the facility since approximately 01/31/23. LPA reviewed R1’s medication lists which show R1’s psychiatric medication was changed while they were hospitalized. AD stated that on 02/08/23, R1 was last seen in the late morning but could not be found during a room check around noon. AD filed a missing persons report with GGPD on 02/08/23. As of today’s inspection, R1 has not returned to the facility. AD stated that AD followed up with GGPD multiple times since 02/08/23. AD stated the facility has a sign-out sheet and encourages residents to sign out when they are leaving, that most residents comply with the sign-out sheet, but that R1 did not sign out on this occasion. AD stated that the facility does not know why R1 left, that there were no events or incidents leading up to R1 leaving, and R1 did not have a change of condition.