Incident investigation·March 14, 2024

Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced case management visit pertaining to a resident eloping from the facility. LPA met with Wendy Rose, the Community Business Director; who was informed the reason of the visit. The Executive Director April Princesa was not available or at the community. During today's visit, LPA conducted a physical plant inspection of the entire facility, including all exit doors and interviewed staff. The following was revealed: On 03/09/2024, resident #1 (R1) eloped from the facility, and was returned back to the community by the local police department. It was revealed to LPA, that R1 is diagnosed with dementia and was currently residing on the AL (Assisted Living) side until an opening for the memory care unit was available. It was also reported to LPA that R1 has a private companion/caregiver that works in the evenings with R1. The companion did not report to the facility to work with R1, the evening of the incident. R1 is not allowed to leave the facility unassisted. The day of the incident, R1 left the facility approximately around 415pm, and staff was not made aware R1 was missing until a phone call received by a bystander who contacted the facility and spoke to the front desk receptionist, who reported, they saw R1 walking down the street from the facility. The bystander contacted the police, who picked up R1 by the freeway and returned to the community. R1 was not aware that R1 eloped and was returned. Staff contacted the Executive Director and family was notified. Therefore, based on interviews, LPA determined there was a lack of care and supervision for R1, which caused R1 to elope and wander. This is an immediate health and safety risk to residents in care. At the end of the visit, LPA spoke to the ED and regarding the visit and citation that was issued. Citation issued, appeal rights, exit interview, and copy of report provided.