Complaint·October 16, 2025

[CONTINUED FROM LIC 9099] According to their LIC602 Physician’s Report, R1 was diagnosed with Alzheimer’s Dementia. Their doctor wrote that R1 was able to walk without any motor impairment or assistive device, but due to their cognitive impairment, R1 was not safe to leave the facility unassisted. Interviews of staff and outside sources unanimously showed that R1 resided in the Assisted Living (AL) section of the facility, where there were neither secured perimeter nor delayed-egress doors present. During the allegation period, Licensee employed a Phillips Roam Alert system at the facility, which helped staff monitor residents in AL who were diagnosed with dementia. The system worked by having selected residents wear a Roam Alert Bracelet device. When such residents came near the thresholds of perimeter door exits, the system would trigger an audible localized alarm at that door and send a wireless signal to the pager devices which the caregivers carried, prompting staff to then redirect the resident away from the door. The system did not physically prevent residents from exiting (such doors remained unlocked from the inside). Licensee’s Phillips Roam Alert system was consistent with CCR 87705, titled Care of Persons with Dementia, which requires Licensees to install “an auditory device or other staff alert feature to monitor exits on exterior doors” that are accessible to residents who “who may be at risk for elopement.” The facility’s written Plan of Operation (on file with CCLD) and Admissions Agreement contract both reiterated that the Roam Alert Bracelet was a safety requirement for any resident diagnosed with dementia living in the facility’s AL section. Licensee’s written Individual Service Plan (i.e., Care Plan) for R1 reiterated that R1 had dementia, was not safe to leave the facility unassisted, and needed to continuously wear their Phillips “Roam Alert Bracelet” for their personal safety. Per manager interviews, Licensee required its caregivers to respond to Roam Alert alarms as quickly as possible, but not longer than five (5) minutes. Staff interviews, corroborated by R1’s Admissions Agreement and an E-mail from a senior manager, also showed that that facility’s exterior exit doors (including the lobby’s front door) were required to be physically locked from the outside at nighttime, for resident safety. The Complainant claimed that on a day in March 2021, they personally observed that R1’s Roam Alert Bracelet wrist strap had been cut, and the device was sitting atop R1’s bedside table; R1 allegedly told them that they had not worn the bracelet “for a while.” Interviews of two facility managers [Staff #1 (S1) and Staff #2 (S2)] showed that at some point during the allegation period, R1’s Roam Alert Bracelet indeed had been cut off/removed, and that S2 subsequently reattached the device to R1. The totality of interviews did not clearly establish how long the Roam Alert Bracelet had been detached from R1 before discovery/correction (making it difficult to evaluate Licensee fault/culpability). [CONTINUED ON LIC 9099-C, 2 of 2] [CONTINUED FROM LIC 812-C, 1 of 2] The Complainant claimed that on a day in March 2021, and again on a day in May 2021, the facility’s front door was not locked form the outside at nighttime, as required. They also claimed that during the May 2021 date, R1’s Roam Alert Bracelet triggered the lobby front door audible alarm, but it took over twenty-five (25) minutes for the first facility staff to respond to it. CCLD subsequently obtained video recording, which was filmed around 9:30 PM on 05/02/2021. The video showed: a) The facility’s front door was unlocked during this night, allowing any person to enter from the outside without staff awareness/involvement; and, b) A loud audible alarm continuously sounded at the lobby front door, which facility staff did not respond to during 13-minute video. The person who filmed the video told CCLD that the video ended there because there was no more storage space on their smart phone camera, but that it actually took staff nearly twice as long to respond to this alarm. Based on records and interviews, a preponderance of evidence exists to show that facility staff did not meet the safety needs of a resident diagnosed with dementia. The allegation is therefore Substantiated, and one (1) deficiency was cited for it per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D page). A Plans of Correction was jointly developed with the Licensee. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. [CONTINUED FROM LIC 9099-A] All chips were also physically carried through multiple exterior exit doors thresholds (to include the lobby front door), for a total of three (3) passes per door. The chips consistently triggered a loudly audible alarm at the door annunciator itself and sent signals to multiple pager devices which the caregivers carried. Both types of alerts continued to be active until staff silenced them by entering a manual key code at the triggering door. This battery of tests, corroborated by interviews of facility managers and frontline caregivers, showed the facility’s egress alert system was reliably working, from a technical/hardware standpoint. Based on records and interviews, a preponderance of evidence does not exist to show that the facility’s egress alert system was unreliable. The allegation is therefore Unsubstantiated, and no deficiency was cited for it. An exit interview was conducted with Health Services Director Keisha Bean, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.