complaint·March 16, 2022

Allegation #1: Facility staff failed to supervise resident, resulting in resident AWOL. It is alleged that on 12/31/2021 that R1 eloped from the facility. According to the information obtained, the day R1 eloped from the facility, R1 was found at least half (1/2) a mile from the facility. The investigation revealed that prior to the incident, R1 was believed to be in their room. R1 wandered out of their room to the far-left exit door located at the back of the facility. Whereas this rear exit door is a delayed egress door, it was inoperable at the time. Care staff did not notice that R1 left the building as they were attending to other residents. After doing resident rounds, staff realized that R1 was not in the facility. Two (2) staff left the facility to find R1. Staff confirmed that they found R1 approximately fifty (50) minutes later and R1 was safely returned to the facility. In response to the incident, staff fixed the delayed egress door, installed cameras and additional alarms. However, on 2/23/22, staff reported that R1 once again eloped from the facility. According to the information obtained, R1 eloped from the facility through the front doors. The investigation revealed that prior to the incident, R1 was in the dining room along with eight (8) other residents and three (3) care staff. R1 wandered out of the dining room and left through the front door near the reception area which is not equipped with delayed egress. Staff that was present in the dining room did not notice that R1 had left the building. Staff had received notifications on their phone alerting them that a door had been opened and care staff failed to respond to the notification immediately. One (1) staff left the facility to find R1. Staff confirmed that they found R1 approximately one (1) block away and was safely returned to the facility. In response to the incident, staff installed an additional alarm to the front door and conducted an in service elopement training and drills. Therefore, based on information obtained and interviews conducted, the allegation lack of supervision resulted in resident eloping, is SUBSTANTIATED at this time. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted, today's reports and appeal rights were reviewed and issued.