374601560-4-27-2023-08-AS-DNGN-CRAUYM-20230427160009

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374601560
Report Date: 04/27/2023
Date Signed: 04/27/2023 04:00:15 PM

Document Has Been Signed on 04/27/2023 04:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	GLENBROOK ASSISTED LIVING		FACILITY NUMBER:	374601560
ADMINISTRATOR:	HARNESS, SADIE		FACILITY TYPE:	740
ADDRESS:	1950 CALLE BARCELONA		TELEPHONE:	(760) 704-6800
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92009
CAPACITY:	95	CENSUS: 75	DATE:	04/27/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Executive Director Sadie Harness		TIME COMPLETED:	04:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by and identified himself to Receptionist Amberdee Ennis. LPA then met and discussed the purpose of the visit with Executive Director Sadie Harness.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 04/25/2023. According to the LIC624: during the early morning of 04/24/2023, Resident #1 (R1) went AWOL (absent without leave) from the facility, without staff witnessing. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] Around 2:25 AM, police phoned facility staff to state R1 was with them. Police then returned R1 to the facility, unharmed/uninjured.

During today’s visit, LPA performed a brief facility tour and interviewed R1, verifying that they were indeed unharmed/uninjured. LPA also reviewed pertinent records and interviewed relevant staff.

According to R1’s LIC602 Physician’s Report (dated 01/26/2023): R1 was diagnosed with “Mild Cognitive Impairment” (but not Dementia) and their doctor determined that they were not able to safely leave the facility unassisted. The doctor wrote that while R1 was “confused/disoriented,” but that they were also “able to follow instructions” and “able to communicate needs.” According to care records and corroborated by interview: R1 was formally assessed pre-move in on 02/03/2023, then reassessed post-move in on 02/16/2023 and 04/23/2023, respectively. Prior to the 04/24/2023 AWOL incident, R1 had no prior elopements from the facility, and did not exhibit any wandering behavior.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GLENBROOK ASSISTED LIVING	FACILITY NUMBER: 374601560
	VISIT DATE: 04/27/2023

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[CONTINUED FROM LIC 809]

Per staff interviews: Since R1 was not at risk for wandering, licensee expected caregiver(s) to visually check on R1 every 2-3 hours. Staff #1 (S1) last saw R1 sleeping inside their bedroom around 12:15 AM. Camera footage showed R1 exited the facility’s lobby/main front doors around 1:45 AM. R1 walked to a shopping plaza directly across the street from the facility. A private security guard spoke with R1, then alerted police, who called facility staff at 2:25 AM to confirm R1’s residency. Police then brought R1 back to the facility around 2:40 AM. Since this AWOL incident, R1 has worn a “wander guard” staff alert device on their ankle (with approval from their physician and responsible party).

During today’s visit, LPA observed the “wander guard” device on R1’s ankle. LPA also observed that the facility’s main/lobby front doors and other perimeter doors were equipped with proximity sensors that interact with “wander guard” devices to alert staff. Facility management explained that all residents are assessed at time of move in, and “wander guards” are considered for those residents who exhibit exit-seeking/wandering behavior.

There does not exist a preponderance of evidence showing that R1’s AWOL resulted from licensee not assessing R1’s needs, or from licensee’s staff not providing needed observation to R1. No deficiency was cited during today's visit.

An exit interview was conducted with Harness, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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