Incident investigation·September 16, 2025

Licensing Program Analyst (LPA) Fred Arias conducted a Case Management visit to the facility to obtain information pertaining to a self reported incident for an elopement involving resident 1 (R1). R1 eloped the facility and returned to their original residence. The facility submitted the incident report on 09/15/2025. The report indicated that the incident occurred on 09/14/2025. LPA observed various residents throughout the facility. Residents in care appeared to be safe; no imminent health/safety concerns were observed. LPA inspected the inside of facility. Facility appeared to be clean and organized. LPA inspected outside perimeter of facility, to ensure no health/safety hazards were present. The needs of the residents in care appeared to be met during LPA's inspection. LPA obtained copies of pertinent documents and interviewed staff. R1 has not returned since the incident occured and is currently at the hospital. LIC602 physician's report indicates R1 may not leave the facility independently. R1's service plan indicates R1 exhibits wandering behaviors. Interviews with staff revealed elopement behaviors were known and one prior elopement was attempted earlier in the day the same day the R1 eloped. R1 was left alone for approximately 6 minutes during which R1 eloped at approximately 12:48pm. Facility notified law enforcement, responsible party, and DHS, Based on today’s inspection a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at facility along with appeal rights.