complaint·May 21, 2025

It was alleged that Resident #1 (R1) who resides in the memory care (MC) unit on the seventh floor of Building B eloped two (2) times. On 04/24/2025, R1 and Resident #2 (R2) went to the second-floor dining room unsupervised and on 05/01/2025, R1 took the elevator outside of the MC unit to the first-floor lobby and walked outside of Building B towards Building C. In both incidents, R1 did not leave facility grounds, was found by staff immediately, and was unharmed, but R1 was unsupervised in the elevator both times that R1 left the MC floor. Staff confirmed that MC can only be entered and exited with a key fob. MC residents do not get their own key fobs, their responsible parties do upon request. MC has two (2) exits, one (1) to the Assisted Living (AL) lobby and one (1) to the parking garage. LPA observed MC with three (3) delayed egress doors and at 12:20PM, LPA confirmed that the MC exit doors to the elevators automatically lock immediately upon closing. Staff stated that the elevators on the seventh floor outside of MC can only go to the first floor without a key fob and not to floors 2-6 which include the main dining room and AL units. LPA interviewed two (2) responsible parties and three (3) staff who stated that R1 and R2 have left the MC floor on multiple occasions but have not left the facility. R1’s physician’s report signed and dated 04/29/2025 documents R1 with a dementia diagnosis and unable to leave the facility unassisted. However, R1 did not leave the facility. At this time, the California Code of Regulations, Title 22 Section 87101(e)(3) Definitions states that “’elopement’ occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee's care, leaves another safe location unsupervised.” As R1 and R2 did not leave the facility unsupervised and were not missing for an extended period of time, the incidents do not fall under the definition of “elopement” at this time. However, on a separate case management report, the facility was cited for lack of care and supervision (see LIC 809). Based on interviews, observation, and record review, the information obtained during the investigation does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation “Resident eloped without supervision while in care” is deemed UNSUBSTANTIATED at this time. No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.