198603384-6-9-2021-28-AS-LHIS-C7QLQU-20211012085808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603384
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:38:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/07/2021 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210607141758

FACILITY NAME:	PASADENA HIGHLANDS		FACILITY NUMBER:	198603384
ADMINISTRATOR:	CANO, KAY		FACILITY TYPE:	740
ADDRESS:	1575 E WASHINGTON BLVD		TELEPHONE:	(801) 815-0808
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	245	CENSUS: 147	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Brodey DeBorde, Executive Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident eloping from facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegation. The purpose of the visit was discussed with Executive Director Brodey DeBorde.

LPA toured the interior and exterior facility grounds at approximately 10:45 am with Health and Wellness Director. The facility has a total of 8 floors. The memory care unit is located in the 1st floor. Resident (R1's) room, all facility floors, common areas, dining room, activity rooms, and outdoor patio area were toured. LPA tested the two delayed egress exit doors in the memory care unit that require a manual code to enter/exit. The main delayed egress door was not working properly; the right side of the door did not sound off after 15 seconds. LPA did not observe any health or safety issues during the time of this visit. Video surveillance of the incident was reviewed with Executive Director. Resident (R1) and a total of five (5) staff were interviewed. The following documents pertaining to resident (R1) were obtained: Face sheet, Physician orders, Physician Report Mini-Mental State Exam, and LIC 500 Personnel Report, resident roster, 7 incident reports.

See LIC 9099C for report continuation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210607141758

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
	VISIT DATE: 06/09/2021

NARRATIVE

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Allegation: “Lack of supervision resulting in resident eloping from facility.” Based on information obtained and interviews conducted, on June 4, 2021 a memory care unit resident AWOL/eloped from the facility at approximately 2:10 pm. Resident (R1) has a Dementia diagnosis and resides in the 1^st floor memory care unit. Resident (R1) was observed in surveillance video to be standing/hiding by dining room door; which is close to the delayed egress door. A staff person exited the memory care unit, and R1 walked out in a hurried manner through the 1st floor lobby exit door, and out through the gated side gate that was opened at the time of the incident. Staff realized R1 had eloped approximately 10 minutes after the resident exited the facility. An immediate search was initiated. Within 20 minutes of not locating the resident 911 emergency was called. A neighborhood resident notified the police department that R1 door knocked at their home. Resident (R1) was found the same day approximately 1 1/2 miles away. Facility staff were contacted by law enforcement and immediately went to pick up the resident. The resident was evaluated upon return. Observations did not indicate the resident sustained any injuries.

All staff confirmed resident (R1's) elopement incident. All staff stated memory care residents are closely monitored. The staff to resident ratio in the memory care unit is 10-1. On the date of the incident there were no staff shortages. Resident (R1) has history of attempted elopements, and one other elopement incident. The previous elopement incident occurred on 7/8/2020. Resident was found across the street. Resident (R1) has not had a change in condition, but has had several recent medication changes. Memory care residents do not have tracking alert devices. The resident’s family was immediately notified of incident. There were a total of four (4) staff working in the memory care unit at the time of the incident. Staff failed to supervise resident (R1), and ensure the door closes after exiting. Resident (R1) was interviewed today but did not recall elopement incident.

Based on records review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 07.

An exit interview was conducted with Executive Director Brodey DeBorde. A copy of the report an appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210607141758

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PASADENA HIGHLANDS	FACILITY NUMBER: 198603384
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/11/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of:	1 2 3 4 5 6 7	Administrator agreed to submit a plan of correction including staff scheduling and supervision of residents. Update resident (R1’s) care plan. In addition, a staff in-service training regarding delayed egress exits, Dementia wandering behavior, methods of redirection, and resident care and supervision shall be conducted by POC due date.
	8 9 10 11 12 13 14	On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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