374604533-6-9-2023-08-AS-DNGN-CSMVCF-20230609161903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604533
Report Date: 06/09/2023
Date Signed: 06/09/2023 04:19:09 PM

Document Has Been Signed on 06/09/2023 04:19 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:	SANTIANNA OAKMONT SIGNATURE LIVING		FACILITY NUMBER:	374604533
ADMINISTRATOR:	THARP, CHRISTOPHER		FACILITY TYPE:	740
ADDRESS:	2560 FARADAY AVE		TELEPHONE:	(442) 325-8090
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92010
CAPACITY:	226	CENSUS: 164	DATE:	06/09/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director Sam El-Rabaa		TIME COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Sam El-Rabaa.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 06/05/2023). According to the LIC624: during a recent evening, Resident #1 (R1), who resided in the facility’s secured memory care unit, eloped from the facility’s building (left without staff supervision). [See LIC 811 Confidential Names List for a description of R1.] R1 was quickly located and returned to the facility staff unharmed/uninjured.

During today’s visit, LPA performed a welfare check, verifying that R1 was indeed unharmed/uninjured. Due to their baseline memory loss, R1 had no recollection of the incident and could not comment on it. LPA also reviewed pertinent care records and interviewed relevant staff.

According to Licensee’s own internal investigation: during the time of the incident, third-party paramedics/EMTs brought a different resident back to the facility’s memory care unit from the hospital. Camera footage was limited but showed that R1 exited the memory care unit using a specific delayed egress door (“Exit Door by 124”), which LPA observed operated on a 30-second delay with a loud, audible alarm (which activates when the door is opened without the staff code being entered on the associated keypad). Licensee interviewed the direct-care staff who worked in the memory care unit during that nighttime shift; none reporting hearing the door alarm go off. Licensee reviewed the electronic log of door alarms, concluding that R1 used the “Exit Door by 124” delayed-egress door without the alarm ever being activated.

[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: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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: SANTIANNA OAKMONT SIGNATURE LIVING	FACILITY NUMBER: 374604533
	VISIT DATE: 06/09/2023

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[CONTINUED FROM LIC 809]

During today’s visit, the camera footage which Licensee reviewed was no longer available for LPA to review (the system overwrites it after a few days). However, LPA reviewed the electronic log of door alarms, finding it was consistent with Licensee’s description. Together with the administrator, LPA observed/tested each of the facility’s delayed egress doors; all worked correctly per California Health and Safety Code specifications. During 5 of 5 tests, LPA observed that direct care staff rapidly responded on foot to the doors to investigate the cause of the alarms.

LPA also observed that the “Exit Door by 124” featured a self-closing arm device, but that this mechanism operated inconsistently. Out of ten (10) times being opened, the door self-closed and fully latched only seven (7) times. The inconsistent self-closing mechanism, in and of itself, does not constitute a regulatory violation. However, it constitutes one way that a resident can open a delayed-egress door which had been earlier disarmed by staff (such as to let someone out), without the alarm being later activated. [Licensee agreed to make adjustments to the door's self-closing mechanism and to retest repeatedly].

Licensee maintained on file a written Absentee Notification Plan for R1, as required. Records showed that Licensee had retrained its staff on its Elopement/Missing Resident Policy on three separate days during early June 2023, to include elopement drills.

Based on the information obtained today, there does not exist a preponderance of evidence to show that Licensee’s staff did not observe R1, or that a lack of staff supervision resulted in R1’s elopement. No deficiency was cited for this specific incident, and no deficiencies were identified/observed during LPA’s site visit today. However, LPA delivered a Technical Advisory/Education regarding 87211 Reporting Requirements.

An exit interview was conducted with El-Rabaa, to whom a copy of this report, the LIC9102-TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC809 (FAS) - (06/04)

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