Incident investigation·April 3, 2025

On 4/3/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit regarding an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting Resident 1 (R1) eloped from the facility on 3/30/2025. LPA met with Administrator, Jolene Farish and Memory Care Director (MCD), Lorena Vivar who were informed of the purpose of the visit. LPA conducted an interview with Administrator Farish and MCD Vivar and both reported the following information. On 3/30/2025 at approximately 6:00 a.m., Resident 2 pulled the fire alarm disarming all exit doors, which were secured with electric magnetic lock systems. At the time, all residents were accounted for and caregivers assessed and secured all exit doors except the courtyard gate. The doors leading to the courtyard gate were not disarmed as they require a keyed entry and were locked when the fire alarm was pulled. As a result, caregivers reportedly overlooked/failed to ensure the courtyard gate was secured. At approximately 5:30 p.m., Staff 1 went to R1's room to check on them but was unable to locate them. Staff conducted a thorough search of the facility but were unable to locate R1. Staff found the courtyard gate closed but unsecured. The facility notified local law enforcement and R1's responsible person. Caregivers reported last seeing R1 at approximately 5:00 p.m. At approximately 8:00 p.m., R1 was returned to the facility by law enforcement. Upon arrival, R1 was assessed and no visible injuries were noted. LPA reviewed R1's Physician's Report (LIC 602A) dated 7/25/2024 noting R1 is unable to leave the facility unassisted. The facility has since conducted an in-service staff training regarding fire alarm and elopement procedures and purchased a new siren alarm for the courtyard gate. On 3/31/2025, LPA received a voicemail from Administrator Farish reporting the incident. LPA reviewed the facility's training and Elopement Drill Records dated 9/24/2024, 12/19/2024 and 2/26/2025 noting the facility conducted routine elopement drills. Although the facility met the reporting requirements timely, trained their staff, and took appropriate action upon learning of the incident, the facility will be cited pursuant to California Code of Regulations (Title 22, Division 6, Chapter 8) regulation 87705(e)(5). During today's visit, LPA did not observe any health or safety concerns. An exit interview was conducted and a copy of this report and Appeal Rights were reviewed and provided to Administrator Farish and MCD Vivar along with Confidential Names list (LIC 811), LIC 809-D.