Follow-up on corrections·July 8, 2025

Licensing Program Analyst (LPA) Hanna Gough arrived at the facility to conducted an unannounced case management deficiency inspection. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Rose Martelloti and explained the reason for the visit. The regional office received an unusual incident report on July 8 th , 2025 regarding an incident that occurred on July 5, 2025. The report stated that Resident 1 (R1) eloped from the facility and was found by a neighboring resident to the facility. Facility staff picked R1 up from the neighboring resident’s home and brought R1 back to the facility. LPA toured the facility, gathered necessary documentation, and conducted interviews. LPA attempted to interview R1 but they could not recall leaving the facility. Upon interview with AD it was revealed that the resident was last seen in the dining room around 1:30pm and was received back at the facility around 4pm, making R1s whereabouts unknown for approximately two and a half hours. AD informed LPA that the facility staff was not aware of R1 leaving the facility until they received a phone call from the police. AD informed LPA that R1 did not have family consent at the time of the incident to leave the facility. AD received the resident back to the facility and conducted a body check for R1, no injuries were noted. AD notified hospice of the incident and had a meeting with R1s family on July 8, 2025. Upon file review LPA observed an in service training that was held on July 5, 2025 regarding an elopement training. LPA reviewed R1 physician’s report dated February 25, 2025, which states that the resident is able to leave the facility unassisted with family consent. Based on today’s inspection a deficiency along with a $500 immediate civil penalty is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Rose Martelloti and a copy of this report, LIC 809D, LIC421IM and appeal rights were given at the time of inspection.