complaint·May 14, 2025

LPA attempted to interview R1 on May 14, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding leaving the facility unattended. R1 stated that they have left the facility in the past but not recently. LPA interviewed R2 who stated that they have lived at the facility too long. R2 stated that they were recently thinking about walking across the street and catching a bus. R2 stated that in the past when they tried to leave the facility unsupervised a staff member yelled at them to get their walker. R2 stated that last month they left the facility and walked to the intersection by themselves. LPA interviewed S1 who stated that the memory care unit was conducting an "elopement drill" right before the incident occurred with R1. S1 stated that the caregiver assigned to R1's section claimed that they "cleared their section." S1 stated that the egress door alarm sounded a short time after and the staff conducted a head count of residents. S1 stated that as they were driving away from the facility they saw R1 outside on the sidewalk area. S1 stated that they placed R1 in their car and drove them back to the facility. S1 stated R1 had no injuries and they estimate that R1 was out of the facility for approximately 10 minutes before R1 was located. LPA interviewed S2 who stated that while driving to work on April 26, 2025 they saw R2 walking towards the street intersection of Olympic Parkway and East Palomar Street. S2 stated that they were worried and immediately called their supervisor to advise them where R2 was located. S2 stated that they do not believe R2 had any injuries as a result of the elopement. S2 stated that R2 lived in the assisted living section of the facility and has eloped from the facility more then three times. LPA interviewed Outside Source 1(OS1) who stated that the facility staff called them immediately after the incident and advised OS1 that R1 "got out of the facility through the back." OS1 stated that the Director contacted OS1 the following day and was apologetic for what occurred. OS1 stated that they do not believe it was a major incident since their were no injuries and R1 simply slipped out. OS1 stated that R1 has never eloped before and they have full confidence in the facility staff. LPA interviewed Executive Director (ED) who stated that on the date of the incident memory care staff were conducting an "elopement drill" and R1 exited the unit. ED stated that the alarm sounded and a head count and room checks were conducted. ED stated that care staff did not accurately count the residents and failed to alert that R1 was missing. ED stated when staff checked the memory care exit door area R1 had walked to far along to be seen. ED stated that the care staff that did not accurately count the residents was place on suspension and was later terminated. ED stated that R2 goes out for walks since their physician's report states they can leave the facility unassisted. ED stated that R2 did walk to the intersection by the facility and R2's family just requests that they do not get lost. Records review revealed an incident report for R1 was submitted to CCL on March 13, 2025. Incident report stated that on March 6, 2025 the memory care egress door alarm sounded off at 410pm. Facility staff did not locate a resident in the surrounding area and conducted a head count. Facility staff located R1 at 417pm outside of the community, walking on the sidewalk. No injuries were noted. Records review revealed R1 had a diagnosis of Alzheimer's. R1 was unable to leave the facility unassisted and R1 was a high elopement risk due to resident expressing they wanted to leave the facility. Records review revealed R2 had a diagnosis of Encephalopathy and a traumatic brain injury with loss of consciousness. R2's physician's report indicated that R2 was non-ambulatory and R2 was able to leave the facility unassisted at their families discretion. R2's care plan stated that R2 had a cognitive impairment, was unable to leave the community unsupervised and they are required to wear a safety bracelet if in assisted living. The Department has investigated the complaint alleging staff did not prevent residents from eloping from facility and staff did not report incidents to appropriate parties. Based on evidence obtained R1 and R2 eloped from the facility and R2's elopement was not reported to the licensing agency. Accordingly, the above allegations are substantiated. This finding means that the preponderance of the evidence standard has been met and the allegations are valid. The deficiencies are cited in accordance with California Code of Regulations, Title 22, Division 6, Chapter 8 and noted on the attached LIC 9099-D. An exit interview was conducted, plans of correction were jointly developed, and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Calais Anguiano, Executive Director. Signature on this form confirms receipt of the documents.