complaint·May 1, 2025

Regarding Allegation: Staff are not properly supervising residents resulting in elopements It is alleged that a resident has been reported missing four times within the last month and a half. RP was concerned of the facility’s security measures and its ability to provide adequate supervision and staffing for the residents. The investigation revealed the following: Based on record reviews, Resident I (R1) was admitted to the facility on March 4, 2025 and was discharged on April 21, 2025. R1 was diagnosed with Dementia and is not able to leave the facility unassisted according to their Physician’s Report dated March 4, 2025. The department received an Incident Reported dated April 20, 2025 indicating that R1 eloped from the facility. R1 was discovered missing again at 7:28 PM on the same day. It was not noted when R1 returned to the facility. Another Incident Report dated March 14, 2025 indicates R1 left the facility again at 12:40 pm. The caregiver (S2) noticed the window was left open. The resident was found at the local Dollar Tree and returned to the facility. Based on interviews conducted, three out of three staff corroborated to the allegation. One resident could not confirm or deny the allegation. All staff confirmed the resident eloped from the facility on April 20, 2025. All staff stated the resident left the facility in the morning around 11:00 AM and was found at a Ford Dealership near the facility by the police. A staff member arrived at the Ford Dealership where the police was with the resident. The police asked the resident if they wanted to be accompanied by the staff or by the police back to the facility. The resident wanted to return to the facility with staff. The resident and staff were heading towards Dollar tree, where the resident hit the staff in the head twice, then ran away from the staff. Staff called 911. S2 and S3 state police found the resident and returned to the facility around 7:00 PM. Then the resident left the facility again around 7:30 PM. S2 and S3 state the police were notified that the resident was missing again and from orders of hospice, when resident returned that the resident needed to go to the hospital to be evaluated. Resident returned to the facility on April 21, 2025, around 2:30 AM. The police were notified by staff that the resident returned. Per orders of hospice, the Police accompanied the resident to the hospital to be evaluated. Continued on LIC9099C Based on LPA’s observations, the facility has four exits from the inside: the main entrance, the garage, the living area, and the resident room #4. All exits have an auditory device, but only the main entrance was operable. The living area and the garage auditory device were turned off, while the auditory device in resident room #4 was not working. S1 and S2 stated they did not know why the auditory devices were not working. LPA observed in room #2 where resident was staying the auditory device was taken off the window. S1 stated the resident would take it off and they just didn’t put it back on the window. A review of Police Report #DR 25-014211 confirmed R1 eloped on April 20, 2025. No Police Report was obtained for the March 14, 2025 elopement incident. Therefore, based on LPA's observations, interviews, and the records reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff are not properly supervising residents resulting in elopements is deemed SUBSTANTIATED as per the California Code of Regulations, Title 22, Division 6, Chapter 8. One deficiency is being cited on the attached LIC9099D. Exit interview was conducted a copy of the report, appeal rights, LIC9099D, and LIC811 were provided to Caregiver Alicia De Guzman.