complaint·November 28, 2023

Staff were not aware that a resident had eloped from the facility. – SUBSTANTIATED. It was reported that Resident 1 (R1) eloped from the facility's memory care unit. Staff were not aware that R1 was missing from the facility until R1’s family came to the facility to visit R1 and R1 could not be located at the facility by staff. R1 was found a substantial distance from the facility and was returned to the facility by a community member. Staff interviews revealed that staff were made aware that R1 had eloped when R1's family came to the facility to visit R1 and R1 was not in the memory care unit. There were two PCAs on duty in the memory care unit and one Med Tech was floating between the assisted living side of the facility and the memory care unit. No one witnessed R1 eloping. Some staff thought that R1 could have eloped through the garden gate but the gate was latched from the inside when staff checked after it was discovered that R1 had eloped. Some staff thought that R1 may have eloped through the front doors of the memory care unit. Staff did not know how R1 had eloped from the facility. Executive Director (ED) stated the last time R1 was seen was at about 2:00 PM and R1 was brought back to the facility at around 3:30 PM. ED stated that the surveillance cameras had malfunctioned during the time that R1 had eloped and therefore there was no surveillance footage for LPA to review to determine whether R1 had eloped through the front doors of the memory care unit. It was determined that R1 eloped from the facility without staff being aware and was out of the facility for about 1.5 hours, unknown to staff. It is unknown how R1 eloped from the facility, there were no witnesses. This allegation is substantiated. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Sonya Gonzales.