374604103-10-30-2020-08-AS-AKEY-BUVTRX-20201030145817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604103
Report Date: 10/30/2020
Date Signed: 10/30/2020 02:59:19 PM

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:	SIENNA AT OTAY RANCH SENIOR LIVING		FACILITY NUMBER:	374604103
ADMINISTRATOR:	MENDEZ, RUBY GOMEZ		FACILITY TYPE:	740
ADDRESS:	1290 SANTA ROSA DR		TELEPHONE:	(619) 550-4521
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91913
CAPACITY:	137	CENSUS: 86	DATE:	10/30/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Erika Hughes		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Kennedy conducted a visit via a video-calling app due to COVID-19 restrictions to conduct a case management visit regarding the elopement of Resident 1 (R1) (See LIC811 for confidential names) on two different occasions recently and reported to CCL by the facility. LPA identified herself and stated the purpose of the video-call to Erika Hughes, Administrator. LPA took a virtual tour of the facility and observed that the delayed egress alarm was working, LPA observed residents involved in activities and observed that all of the staff had masks on. The first incident was on 10/23/20. R1 eloped from the memory support unit through the main door to the facility lobby and out the front door of the facility. A review of surveillance video determined that R1 walked out of the front door at 10:15 PM. The facility nurse was doing a training for the staff at that time and the most likely scenario is that R1 followed a staff member through the Memory Support unit exit as the the staff member was leaving the training . R1 was away from the facility for approximately 2 hours and was returned to the facility by Law Enforcement. Staff was unaware of the elopement until R1 returned. R1 presented to a neighborhood guard station less than a block from the facility. R1 gave their accurate name and date of birth.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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: SIENNA AT OTAY RANCH SENIOR LIVING	FACILITY NUMBER: 374604103
	VISIT DATE: 10/30/2020

NARRATIVE

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The police knew R1 lived at the facility and escorted R1 back to the community. There was no police report generated. R1 was evaluated upon return and no injury or other concern was noted.

The second incident was on 10/29/20 when R1 pushed the delayed egress exit in the back of the facility at approximately 9:00AM. The alarm sounded, a care partner responded to the alarm and found another resident near the exit and assumed that the other resident pushed the exit bar setting off the alarm. The staff member redirected the other resident and rearmed the delayed egress unaware R1 had exited the facility. The concierge noticed R1 was outside the facility on the surveillance camera and the memory support director and the health and wellness escorted R1 back to the unit. R1 was assessed and no injury was noted.

R1 was reassessed by the director of health and wellness on 10/29/20 and as a result of the reassessment status checks will be increased to hourly both day and night, R1's activities will including multiple supervised walks per day, and inviting R1 to assist with community chores, additionally R1 will have 4 hours of 1 to1 companionship per day with a private care provider who may take R1 outside the facility for walks.

No health and safety concerns were identified during the televisit and no violations were cited.

An exit interview was conducted with Erika Hughes, Administrator via video-call. A copy of this report along with Licensee Rights (LIC9058 01/2016) was provided to Ms. Hughes via email. An electronic response confirms the documents were received.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Anna Kennedy	TELEPHONE: (619) 997- 4108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC809 (FAS) - (06/04)

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