complaint·June 9, 2021

Allegation: “Lack of supervision resulting in resident eloping from facility.” Based on information obtained and interviews conducted, on June 4, 2021 a memory care unit resident AWOL/eloped from the facility at approximately 2:10 pm. Resident (R1) has a Dementia diagnosis and resides in the 1 st floor memory care unit. Resident (R1) was observed in surveillance video to be standing/hiding by dining room door; which is close to the delayed egress door. A staff person exited the memory care unit, and R1 walked out in a hurried manner through the 1st floor lobby exit door, and out through the gated side gate that was opened at the time of the incident. Staff realized R1 had eloped approximately 10 minutes after the resident exited the facility. An immediate search was initiated. Within 20 minutes of not locating the resident 911 emergency was called. A neighborhood resident notified the police department that R1 door knocked at their home. Resident (R1) was found the same day approximately 1 1/2 miles away. Facility staff were contacted by law enforcement and immediately went to pick up the resident. The resident was evaluated upon return. Observations did not indicate the resident sustained any injuries. All staff confirmed resident (R1's) elopement incident. All staff stated memory care residents are closely monitored. The staff to resident ratio in the memory care unit is 10-1. On the date of the incident there were no staff shortages. Resident (R1) has history of attempted elopements, and one other elopement incident. The previous elopement incident occurred on 7/8/2020. Resident was found across the street. Resident (R1) has not had a change in condition, but has had several recent medication changes. Memory care residents do not have tracking alert devices. The resident’s family was immediately notified of incident. There were a total of four (4) staff working in the memory care unit at the time of the incident. Staff failed to supervise resident (R1), and ensure the door closes after exiting. Resident (R1) was interviewed today but did not recall elopement incident. Based on records review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . Deficiency is being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8, Article 07. An exit interview was conducted with Executive Director Brodey DeBorde. A copy of the report an appeal rights were provided.