Incident investigation·September 4, 2025

On 9/4/2025 at 10:00am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to conduct a Case Management – Incident visit. LPA met with Administrator Carl Meyer and explained the purpose of the visit. On 9/2/2025 at 5:20pm Community Care Licensing (CCL) received an incident report via email from the facility stating that on 8/24/2025 at approximately 10:15am Resident #1 (R1) was reported missing. R1 was last seen walking out the back door by Staff #1 (S1). A staff-wide search was initiated and approximately 30 minutes later R1 was found at Kennedy Club Fitness. LPA record review of R1’s LIC602A Physician’s Report indicates R1 is diagnosed with dementia and is not able to leave the facility unassisted. R1 resides in Compass Rose, the facilities memory care unit. LPA toured the memory care unit with Staff #2 (S2) ensuring the 4 doors in memory care with egress devices are functioning properly. S1 is an agency staff brought in by the facility to cover open shifts. S1 was assigned to work in Compass Rose on 8/24/2025. Staff interviews reveal that S1 told other staff that R1 was trying to exit the egress door in the back of the unit leading to the parking lot. When S1 attempted to redirect R1, R1 began to hit S1 and S1 let R1 out of the facility through that door. Interviews revealed S1 changed their story multiple times and the timing of how long they let R1 out the door ranged from ten seconds to thirty minutes. At approximately 10:15am when S1 told other staff what happened the other staff notified lead staff on duty, Staff #3 (S3). S3 activated the facilities elopement protocol and a facility search began inside and outside the facility. S3 notified the administrator at 10:24am. (Continued on LIC809-C) S3 called R1's responsible person and left a voicemail. At approximately 10:45am Kennedy Club Fitness called the local police to assist R1. When the police arrived they called the facility to see if R1 lived here and the police returned R1 to the facility. Not long after R1's returned to the facility R1's responsible person arrived and facility staff reviewed the incident with them. Administrator admitted no one notified the licensing agency Officer of the Day, by telephone, e-mail, fax, or hand-delivery no later than the next working day following the incident. The first notification to CCL was the emailed incident report dated 9/2/2025 at 5:20pm, nine days after the incident. LPA conducted a visit to the facility on 8/27/2025 and Administrator did not mention the elopement then. When asked why CCL had not been notified per Title 22 regulation the Administrator admitted he must have overlooked it. Administrator and S2 state the four egress doors in Compass Rose are checked to ensure proper functioning monthly. Per facility protocol a monthly elopement drill is conducted with staff and record review shows the facility conducted drills following the incident and the previous two were conducted on 7/31/2025 and 6/26/2025. Record review of S1's training from the agency does not list any dementia training and the facility was unable to provide dementia training for S1 meeting the Health and Safety Code requirements. Exit interview conducted, deficiencies cited on LIC809-D pages, report signed, appeal rights and report provided to Administrator.