Incident investigation·March 13, 2025

At approximately 1:00PM, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Business Director, Karina Vasquez. The purpose of the visit was to follow up on self reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 02/21/2025. Report stated that on 02/14/2025, Resident (R1) who is ambulatory with and without a device, eloped from community around 11:00am. Memory Support alarmed doors notified staff that someone exited from Memory Support Unit but when checked it was found out to be a visitor exiting without the code. Med Tech did resident check per protocol and did not see R1. Staff began to search for missing resident. First responders notified community that resident was found safe off premises 0.8 miles away and HSA in response to code found R1 with first responders around 11:10am. R1 was returned to community after EMTs found no need for resident to be transported to the emergency room as R1 was in no need of medical attention and staff member was with R1 awaiting return to community. (Deficiency Cited) Per R1s physician's report (LIC602) R1 is diagnosed with dementia and is unable to leave facility unassisted. Based on conversation with Business Director, No one knew how R1 got out. Facility conducted an in-service training for memory staff for elopement the same day (02/14/2025) as the incident happened. Facility conducted an all staff elopement training on 02/19/2025. See LIC809-D for Deficiency. Exit interview conducted with Business Manager and a copy of this report along with LIC811 (Confidential Names) was provided .