complaint·April 7, 2025

R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time. LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note. R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents, which will be addressed in a separate report. [continued on 9099-C] LPA Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care conference to discuss having a one-on-one caregiver for R1 between 3 p.m. and 9 p.m. due to R1 "leaving the building a number of times" and because R1's use of "the back door has escalated and it is challenging to keep [R1] safe." A manager sent another email to R1's RP on 3/29/24 informing them that the rate for one-on-one caregivers was $35 per hour, and notified them that this would be added to their bill. R1's RP sent an email to Cortez on 4/5/24 while discussing the potential for daytime one-on-one hours. R1's RP said that they "insist the initial 'sundowning' hours from 3pm to 9pm remain until we find an alternative." LPA Moleski reviewed R1's billing statements. Starting from 3/29/24, R1 was charged for a total of 40 hours of one-on-one care, totaling $1400 at a rate of $35 per hour, which is just under seven days of one-on-one care given the hours of 3 p.m. to 9 p.m. R1's last day at this facility was 4/9/24, 11 days after 3/29/24. In an interview, Cortez said R1 was not charged for all of the one-on-one care that was provided as a courtesy. Health and Safety Code Section 1569.657(a) states that rates for care may be increased, provided that written notice of the increase providing an explanation of charges is provided to the resident and the resident's responsible party. The requirements of this section appear to have been met based on the emails reviewed by LPA Moleski, given that management explained to R1's RP the rate of the increase and the need for the increase over several emails with sufficient advance notice pursuant to §1569.657(a). On 4/5/24, Cortez sent an email to R1's RP informing them that the night before, R1 had gone out for a walk in the rain trying to look for a friend's car while accompanied by care staff. A narrative charting note dated 4/4/25 corroborated this incident. Cortez went on to say in this email that R1 "has progressively gotten more agitated with the staff who are working with [R1]" and that "at this point I don't believe [R1] is appropriate for Assisted Living. I feel [R1] would do better in a larger memory care setting ... Of course I would love to retain [R1] in our memory care but we are unfortunately full at this point and I am unsure when we will have an opening ... We of course will continue to have him reside in our Assisted Living until he can find another placement in a memory care facility." On 4/8/24, R1's RP said the following in an email response to Cortez: "Thank you for the suggested alternatives for memory care. We have chosen one of them and will be moving [R1] tomorrow..." In interviews, both Cortez and R1's RP agreed that no eviction notice had been served. [continued on 9099-C] LPA Moleski reviewed meal attendance tracking sheets during R1's period of residency, from 3/19/24 to 4/9/24. LPA Moleski observed seven meals for which R1's attendance in the dining room was not recorded. No staff member interviewed was aware of any instances in which R1 had not been provided meals while at the facility. Staff members interviewed indicated that R1 would be brought room service if they did not want to eat down in the dining room. Narrative charting notes for R1 indicated that R1 often preferred to stay in their room for most of the day. According to R1's RP, R1 has severe memory issues and would not be able to recall any events from their time at this facility. The department has determined the following as it relates to the allegations that the facility illegally evicted a resident in care, that staff overcharged a resident in care, and that staff did not ensure a resident was provided meals: Based on interviews and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Cortez. R1's preplacement appraisal also noted a diagnosis of dementia, but also indicated R1 was active and did not require personal help with most activities. The preplacement appraisal does not mention any significant concerns regarding R1's cognitive abilities at the time. LPA Moleski reviewed narrative charting for R1 dated from their move-in on 3/19/24 to their departure from the facility on 4/9/24. A note on 3/24/24 indicated that R1 had attempted to elope from the facility around 12:38 p.m. According to the note, R1 was escorted back inside from the rear parking lot, where they had been trying to open car doors. In an interview, S1, who escorted R1 back inside, said they heard the door alarm going off and followed R1 out, eventually redirecting R1 and bringing them back into the building without further incident. Another note from 3/24/25 around 10:26 p.m. indicated that R1 had gone out of the building and "walked off towards the road." R1 said they were going for a walk when they were found by a caregiver, who walked R1 back to their room, according to the note. In an interview, S2, the author of the note, confirmed the incident described in the note, and confirmed that R1 was alone outside of the building. A note dated 3/26/24 stated that R1 eloped out through a back door, and was found walking back in through a different set of doors. In an interview S2, the author of this note, said they did not see R1 outside, and by the time they responded to the door alarm R1 was already walking back inside on their own. A note dated 3/28/24 stated that an alarm went off around 3 p.m. R1's friend was present in their room, and told staff that R1 had gone for a walk around the building, per the note. R1 was found by staff walking behind the facility, according to the note. In an interview, S3, the author of the note, confirmed the events described in the note. R1's LIC 602 did not address whether or not R1 was permitted to be outside the facility unaccompanied by staff. The location on the LIC form used to identify whether or not R1 would be at risk when outside on their own was left blank. However, an assessment for R1, effective as of 3/19/24, indicated that R1 needed total assistance or wheelchair escorts to and from activities and meals, that R1 needed extensive psychosocial supports and behavioral interventions, and that R1 suffered from memory impairment, suggesting that R1 needed continuous supervision to maintain their safety. Based on the above, the facility did not prevent R1's elopements and/or did not accompany or supervise R1 during all elopement incidents in order to ensure R1's health and safety while out of the building. LPA Moleski reviewed email conversations between facility management staff and R1's RP. On 3/28/24, a manager sent an email to R1's RP requesting a care conference to discuss having a one-on-one caregiver for R1 between 3 p.m. and 9 p.m. due to R1 "leaving the building a number of times" and because R1's use of "the back door has escalated and it is challenging to keep [R1] safe." [continued on 9099-C] The department has determined the following as it relates to the allegation that staff did not prevent a resident from eloping from the facility: Based on interview and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.312(e). An exit interview was held with Cortez. Appeal rights and a copy of this report were left with Cortez.