Complaint·October 16, 2025

On June 12, 2025, the Department received a complaint alleging that staff did not prevent resident from leaving the facility unassisted resulting in R1 eloping from the facility and requiring hospitalization. The Department reviewed facility records, medical documentation, and staff schedules, and conducted interviews with staff, witnesses, and the Executive Director. The Department also reviewed R1’s physician’s report, care plan, charting notes, and prior incident history regarding wandering and attempted elopement. On June 7, 2025, at approximately 5:20 PM, R1 eloped from the facility without staff’s knowledge. Records confirmed R1 was diagnosed with dementia, required assistance with ADLs, and had a documented history of wandering and exit-seeking behaviors, including prior attempted elopements on 06/30/24, 06/19/24, 06/09/24, 07/12/24, 04/12/25, 04/13/25, and 05/30/25. Caregiver (S1) last observed R1 in the facility at 5:15 PM during shift change. Oncoming caregiver (S2) reported being ill and immediately used the bathroom after arriving on shift, leaving residents unsupervised. While S2 was in the bathroom, R1 exited the facility. Facility charting confirmed R1 was missing from approximately 5:20 PM until approximately 6:20 PM, when R1 was found by a neighbor on their porch. The neighbor called 911. EMS transported R1 to Local Hospital. Medical records confirmed R1 was admitted and treated for urinary tract infection, sepsis, and dehydration, and remained hospitalized until June 10, 2025. Executive Director (S3) acknowledged the facility was aware of R1’s history of wandering but had not updated the care plan to include closer supervision or additional safety measures. Interviews with staff confirmed door alarms were not audible throughout the facility, and no staff were monitoring exits at the time of the incident. Based on observations, interviews conducted, and record reviews, the preponderance of evidence standard has been met. The facility failed to provide adequate care and supervision to ensure R1’s safety, which resulted in R1 eloping unsupervised for approximately one hour and being hospitalized for sepsis and dehydration. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87463, is being cited on the attached LIC 9099-D. A civil penalty in the amount of $500 is assessed. The licensee was informed during today’s visit that a civil penalty is under review and may be assessed at a future date according to Health and Safety Code §1569.49 . Exit interview conducted. Appeal rights provided. Report left with facility Administrator.