Incident investigation·February 18, 2025

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with MJ Cabreara, House Manager, stating the reason for today's inspection. Administrator, Zadel Cabrera, was contacted and indicated she was unavailable during the inspection. The Department received (2) incident reports (LIC624) on February 14, 2025, reporting the following: The LIC624 from February 12, 2025 states that at 1:45 pm, (R1) stated they wanted to go to the store and left the house. The report notes that a caregiver tried to stop resident from leaving as they cannot leave the facility unattended but the resident stated they can do what they want. The facility contacted the police to stop (R1) but the police stated they cannot stop the resident. The facility called 9-1-1 to take resident to the hospital for a change in condition due to increased confusion, but the resident refused to go . The police stated resident can make their own choices since they are not conserved. (R1) agreed to return to the care home providing the care giver take them to the store. The LIC624 from February 13, 2025 states around 1:00 pm, (R1) was found to be missing from the home and the police was contacted after an immediate search was done. (R1) was found walking in the rain and agreed to return to the facility if caregiver took them to the store again. (R1) was brought back and attempted to leave one more time that afternoon, when waiting for the ambulance, around 4:00 pm. The Administrator contacted LPA promptly after (R1) was observed missing and stated that (R1) was smoking on the back patio, and staff went to care for another resident. When the staff had returned (10) minutes later, resident had left the facility. (R1's) physician's report, dated August 14, 2024, indicates that (R1) is not able to leave the facility unattended due to her mental status. The Administrator was contacted by the emergency room physician after (R1) was sent there to advise that (R1) would be transferring to a secured memory care. Per California Code of Regulations, Title 22, Chapter 6, Division 8, the following (1) citation is issued on the 809-D page. Exit interview. Copy of report and appeal rights provided.