Incident investigation·September 8, 2023

Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of following-up on an incident report received by Community Care Licensing on 9/01/2023. LPA met with Staff 3 (S3), Resident Care Coordinator Samantha Lole and explained the reason for the visit. Incident report indicated that on 8/31/2023 at about 8:00 p.m., Resident 1 (R1) could not be located by facility staff. Police were called and it was determined R1 had been found offsite and transported to a local hospital where they were treated for dehydration. During today’s visit, LPA was unable to interview R1, as they have since been relocated to another assisted living facility. LPA interviewed additional residents, and staff present during the incident. Residents interviewed did not report witnessing R1’s elopement and staff were unable to determine R1’s point of exit or elopement route. LPA obtained and reviewed R1’s Physician Report (LIC 602) dated 8/24/23, which indicates R1 is not able to leave facility unassisted. Based on observation made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, a copy of this report, and appeal rights was left at the facility.