complaint·September 11, 2025

R1's Individualized Service Plan dated August 15, 2025 states that R1 is ambulatory and is unable to leave the facility unsupervised. Service plan further states that R1 is required to wear their safety bracelet if they are in the assisted living section of the community. LPA interviewed R1 who stated that less then a week ago they exited the facility without any supervision. R1 stated that they wanted to take a walk so they walked down the stairwell and exited the facility onto the sidewalk. R1 stated that they did not injure themselves during their walk but they did feel dehydrated. R1 stated that they now have a private caregiver who takes them for walks outside of the facility LPA interviewed Staff 1 (S1) who stated that on the date of the incident a woman called the facility advising staff that a person was found walking down the sidewalk who appeared lost and confused. The woman was able to confirm with R1 their identity. S1 then drove to pick up R1 who was with law enforcement. S1 asked R1 "what happened." R1 replied that they went for a walk and got lost. S1 stated that R1 was located approximately three blocks from the facility. S1 was unable to confirm how long R1 was outside of the facility unsupervised. LPA interviewed Staff 2 (S2) who stated that R1 eloped from the facility on the second day that R1 was admitted. S2 stated that R1 resides on the second floor in the assisted living section of the facility. S2 stated that R1 exited the facility from a stairwell on the second floor that exits onto the sidewalk. S2 stated that R1 was out of the community for approximately two hours. S2 stated that R1 was picked up by S1 and brought back to the facility. S2 stated that R1 now has a private caregiver that was provided by R1's responsible party. On September 3, 2025 CCL received an incident report (IR) regarding R1. IR stated that on September 2, 2025 the facility received a telephone call from a neighbor advising them that R1 was seen walking by the nearby homes. R1 was immediately picked up by facility staff. R1 returned to the facility without any visible injuries. After R1 showed facility staff the exit they took, staff concluded that they "cleared the alarm" without realizing that a resident had exited the facility. The Department has investigated the complaint alleging staff did not prevent R1 from eloping from facility. Based on evidence obtained R1 eloped from the facility on September 2, 2025. Accordingly, the above allegation is substantiated. This finding means that the preponderance of the evidence standard has been met and the allegation is valid. The deficiency is 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, a plan of correction was developed by Trobell Orana and a copy of this report and Licensee/Appeal Rights (LIC 9058) were provided to Trobell Orana whose signature on this form confirms receipt of the documents.