Complaint·August 21, 2024

Interview with BSD indicated that they observed R1 inside the facility walking with their walker at approximately 5:30 PM. Facility records showed that R1 was in the dining room for dinner, which is served between 4:00 PM to 6:00 PM. Police Department dispatch call records indicate that facility contacted local police department at 7:14 PM to report R1 missing. Interview with RCD indicated that they made the 9-1-1 call. Dispatch call records indicate that RCD reported to police department that R1 was last seen by staff at 3:45 PM. Missing Person Report indicates that R1 was last seen at approximately 3:45 PM and not reported to police department until 7:00 PM that same day. Report indicates that staff stated R1 is often very confused and gets lost very easily. Report indicates that R1 was found by officer in the woods to the rear of the facility, in which R1 was stuck in tall brambles. Interview with ED indicated that, after conducting an internal investigation following the incident and prior to reporting to CCLD, the facility discovered that BSD had last seen R1 inside the facility at 5:30 PM. Interview with RCD indicated that, when they reported to 9-1-1, the staff who they spoke with reported last seeing R1 in the facility at 3:45 PM and RCD reported such to local police department. Interview with RCD indicated that staff at the facility did not report R1 missing to RCD until 6:41 PM, 41 minutes after staff observed R1 missing. ED and RCD stated that, following incident, R1 has moved to a higher level of care outside the facility. During visit, LPA observed field behind property to be maintained. LPA observed that R1's LIC 602A Physician's Report dated 4/16/2024 indicates that R1 has Mild Cognitive Impairment and is unable to leave the facility unassisted. Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page. Exit interview was conducted with ED. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.