complaint·November 9, 2023

on April 30, 2022 when R1 started to reside at the facility. Prior to being admitted to the facility, R1 had previously been admitted to two other board and care facilities and eloped from both homes within 24 hours of being admitted. Interviews with facility staff confirmed the facility received R1’s hospital discharge paperwork from Kaiser Hospital on April 29, 2023, at 11:15 AM what is approximately 10 hours prior to R1 residing at the facility. Although the Licensee reported not reading the paperwork and that the hospital had dropped R1 off blindly, interviews with the facility Administrator Hyo Sok Kim disclosed that they were aware of R1’s exit seeking behaviors and combative and believed R1 would be easily controlled using medications. Kaiser Hospital discharge records dated April 14, 2022, confirmed R1’s diagnosis of dementia with behavioral d isturbances and exit seeking behaviors. On May 6, 2022, two of three staff interviewed reported that R1 had become combative with staff and exited the facility memory care unit. At the time of the incident, staffing records show only Staff 1 (S1) was working at the facility memory care unit. After exiting the memory care unit, R1 continued to the facility entrance. At approximately 11:30 AM R1 eloped from the facility unassisted. Despite knowing R1’s history and seeing R1 walk out of the facility, no staff followed behind to provide R1 with supervision when exiting. S2 contacted La Habra Police to report R1 missing at 1:49 PM, approximately three hours after R1 left the facility. On May 4, 2022, R1’s remains were discovered by the San Bernadino Sheriff’s Department (SBSD) after being struck by a vehicle driver on the 10 freeway. The autopsy report obtained lists R1’s cause of death as multiple blunt force injuries, instantaneous. Despite being made aware of R1’s behaviors and history of exit seeking, the facility still chose to admit R1 to the facility as agreed upon per signed admission agreement. By accepting R1 to the facility, the facility agreed to provide care and supervision as necessary to meet R1’s needs. Facility Administrator Hyo Sok Kim admitted she had filled out R1’s paperwork prior to R1 being admitted and assessed. Despite being provided with R1’s history of exit seeking and behaviors, R1 failed to be properly assessed and later it was determined R1 was not a good fit for the facility. Licensee Eric Doan stated the facility had not received R1’s paperwork prior to being admitted and that the hospital had dropped R1 off after hours and on the weekend. This was a false statement as investigation revealed that the facility did in fact received R1’s paperwork prior to R1 being admitted. They were expecting R1 in advance of them being placed with the facility but failed to properly conduct an assessment. CONTINUED ON 9099-C... On May 1, 2022, R1 eloped from the facility at approximately 11:30 AM after becoming agitated with S2. No staff followed behind R1. S2 awaited until 1:49 PM, approximately 3 hours later, to notify La Habra Police R1 was missing. Despite signing the agreement, the facility failed to provide proper supervision resulting in R1 eloping from the facility and dying three days later. Therefore, based on interviews conducted and records reviewed the allegation that Resident went AWOL from the facility due to lack of care and supervision has been deemed Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. A Civil Penalty is pending determination by Community Care Licensing Division as per Health & Safety Code 1569.49(e) An exit interview was conducted, and a copy of this report, 9099-D Page, and Appeal Rights were left at the facility.