Incident investigation·November 18, 2024

On 11/18/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit . El Segundo Regional Office received an LIC 624 Incident Report (dated: 11/11/24). Information revealed on 11/05/24, approximately 01:00 am, (R1) from Arbor Hall was discovered not in the room or any part of the facility. The care staff on duty search for (R1) outside grounds of the facility but did not find (R1). The care staff contacted the Carson Sheriff's Department. On 11/12/24, (LPA) Dabuet followed up with Administrator and was informed not having any notion how (R1) was able to leave the Arbor Hall (memory care unit) when exit doors are controlled egress locking system. The facility is also has surveillance cameras in the common areas to monitor daily activities. The Resident Care Coordinator contact local emergency rooms in search for (R1). Later late afternoon on 11/12/24, (R1) was found by Fullerton Police Department and was taken to Anaheim Global Hospital for observation. Interviews with the Administrator and Resident Care Coordinator verified (R1) eloped from the facility without care supervision. A review of (R1's) Physicians Report LIC 602A (dated: 03/31/23) revealed that (R1) has wandering behavior and is not able to leave the facility unassisted. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, "NEGLECT and LACK OF CARE AND SUPERVISION". California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with Gabby Eusebio, Resident Care Coordinator and a hard copy of the report along with appeal rights.