Incident investigation·April 17, 2024

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced case management visit in regard to a self reported incident that occurred on 04/01/2024. On that date Resident # 1 (R1) was observed outside of the community by Staff #1 (S1) while driving outside of the community. S1 then informed staff at the community who then confirmed R1 was not in the community. R1 was brought back to the facility by S1 without any injuries or health concerns. Between 01:00pm – 03:30pm, LPA conducted a physical plant, interviewed staff and reviewed and obtained copies of pertinent documentation relevant to the incident. Interviews conducted and records review revealed that R1 walks around the community often with their private caregiver or staff, however during that time frame that R1 eloped from the facility R1's private caregiver was not with R1.  In addition, Record review revealed that R1 is unable to leave the facility unassisted, is diagnosed with dementia, and is ambulatory. Following the 04/01/2024 elopement, staff had completed a new needs and service assessment for R1 identifying the need for use of wearing a wander guard. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted/Citations issued/ Appeal Rights Discussed/ Copy of this report issued.