Incident investigation·August 2, 2024

On 8/2/2024 at 9:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced for a case management visit concerning the 7/28/2024 incident with Resident R1 who eloped from the facility. Upon entering the facility, the LPA stated the purpose of visit to Executive Director (ED) Linda Nguyen. During the visit, the LPA interviewed the ED and Health Service Director (HSD) Sarah Summers about the incident. The HSD explained what had occurred on 7/28/2024 when R1 eloped. R1 moved into the facility on 7/17/2024 into Assisted Living. The HSD stated that though R1 wore a WanderGuard and the staff responded quickly when notified that R1 had left the building, R1 is a very fast walker and had left before staff arrived. In their post incident follow up, family member F1 stated that R1 had been "triggered" to elope due to family issues. Because this event revealed the potential risk of R1 eloping again in the future, on 8/5/2024, R1 will be moving into a memory care unit in a different facility. No citations issued during this visit. Exit interview was conducted with the ED. A copy of this report was provided.