Incident investigation·February 4, 2025

On February 4th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit due to an incident report that was received by the Orange regional office. Special Incident Report (SIR) was submitted stating that an elopement had occurred. Upon arrival LPA Vanegas was greeted and granted entry by caregiver Richard Robles. LPA Vanegas explained the nature of the visit and began to review staff files and file of resident that eloped. LPA Vanegas reviewed all staff files, and observed the following all staff on duty have updated training on elopement procedures and have completed required annual training. LPA Vanegas observed resident's file and reviewed physicians report. Per LPA Vanegas review of physicians report resident is diagnosed with blindness, anxiety, and depression. Resident is able to leave facility unassisted however, they need their walking cane if leaving the facility. LPA Vanegas interviewed staff member Richard Robles and was given the following information. Per staff member resident left the facility at some point in the middle of the night. They were unaware of what time it was, but it was after they have all gone to bed for the evening. Resident left pillows under their blankets to make it appear as if there was an individual under the blankets. Resident climbed out of the window and left their walking stick behind. At 7:00AM staff member Richard attempted to wake resident up for breakfast and realized resident was gone. Later that day they received a call from a concerned citizen stating that resident was at the Dana Point post office. An uber was ordered for resident and he was returned the facility safely and unharmed. LPA Vanegas interviewed resident and resident stated that they left on their own with out a walking stick because they wanted to prove to themselves that they can still do things on their own without any help. Resident stated that it was not any negligence or lack of supervision that caused him to leave, but that he did it on his own will and broke his screen to get out of his room. CONTINUED ON LIC809C Resident is high functioning and is now able to leave facility with out being assisted. Based on today's observations no health or safety concerns were noted and no deficiencies were cited on today's date. An exit interview was conducted and a copy of this report was left at the facility.