Incident investigation·July 10, 2025

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Executive Director (ED), Alicia Rist, to conduct a case management visit. The purpose of today's visit is to follow up on an Unusual Incident/Injury Report (SIR) that was received by the Department on July 7, 2025. On July 7, 2025, the Department received an SIR indicating that, on July 5, 2025, staff were unable to locate resident (R1) on the premises after attempting to escort R1 to breakfast. SIR states that facility initiated elopement protocols after determining that R1 was not on the premises, including contacting R1's responsible party (RP), local law enforcement, and local hospital. RP was able to reach R1 via cell phone. R1 was located at their residence and escorted back to the community via facility staff. R1 was last seen in their apartment at 7:34 PM on July 4, 2025. R1 exited their apartment at 7:42 PM on July 4, 2025. R1 was picked up at their residence at approximately 10:30 AM on July 5, 2025 after locating R1. R1's residence is located approximately five (5) miles away from the community. Facility identified that wanderguard for R1 did not function as intended and maintenance repaired wanderguard after incident. Facility also identified cameras within the community did not cover certain exits in which R1 could have exited the community. Camera coverage throughout the community is being evaluated and rectified. SIR indicates that R1's care plan is being updated and family will arrange for additional hours for 1:1 companionship for R1. R1's Medical Assessment LIC 602A dated June 26, 2025, indicates that R1 has Mild Cognitive Impairment (MCI). R1's LIC 602A states that R1 is not able to leave the facility unsupervised with a note stating, "has memory problems and need to be supervised at the beginning. [R1] can leave the apartment but can not leave the facility unsupervised." ** Report continued on 809-C ** As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87464(f)(1) regarding Basic Services in relation to care and supervision. The deficiency is listed on 809-D. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.