Incident investigation·April 16, 2025

On 4/16/2025, 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 4/4/2025. LPA was informed Administrator, Jolene Farish was not present in the facility and unavailable to meet with LPA. As a result, LPA met with Administrative Executive Director (AED), Reu Baggao and Resident Services Director (RSD), Ana Ramirez who were informed of the purpose of the visit. LPA conducted an interview with AED and RSD who reported on 4/4/2025 at approximately 11:00 a.m., the fire alarm near room 502 (memory care unit) was pulled, which caused all exit doors to be automatically disarmed. Facility staff conducted a resident head count and discovered R1 missing. Staff reported R1 was last seen 10 minutes prior to the fire alarm being pulled. The facility contacted law enforcement who located R1 a mile away from the facility. R1 was returned to the facility by Administrator Farish and RSD. R1 was assessed by paramedics and no apparent injuries were noted. LPA reviewed R1's Physician's Report (LIC 602A) dated 1/13/2025 noting R1 is unable to leave the facility unassisted. LPA also reviewed R1's appraisal dated 1/19/2025 noting concerns due to R1 having a history of eloping. LPA toured the facility with RSD and observed six (6) fire alarm pull stations with lid covers available for emergencies. LPA reviewed the facility's staff schedule for the week of 3/30/2025 noting four (4) caregivers were present on 4/4/2025 when the incident occurred. On 3/30/2025, Resident 2 also eloped from the facility/memory care unit after one of the fire alarms was pulled. As a result, civil penalties will be assessed during today's visit. No additional health or safety concerns were observed during today's visit. An exit interview was conducted and a copy of this report, LIC 809-D, Confidential Names list (LIC 811), LIC421FC, and Appeal Rights were reviewed and provided to AED.