Incident investigation·April 16, 2025

Licensing Program Analyst Manuel Monter conducted an unannounced case management visit-incident regarding an incident report, which stated a resident had eloped from the facility. LPA was also conducting a POC visit LPA met with Memory Care Director (MCD) Evelyn Lax. LPAs explained the purpose of the visit. On April 7, 2025, the Department received an incident report (LIC624) regarding a resident (referred as R1) who eloped from the facility. According to the report, on April 5, 2025, around 4pm, resident R1 got out through the side gate. R1 was found by members of St. Christopher’s Church. Members of St. Christopher’s Church called R1’s family member with his/her phone. R1 was brought back to the facility by his/her family who met R1 there. On April 7 and April 10, 2025, LPA Monter interviewed ADM James Mortensen and Staff S1. ADM and S1 stated R1 doesn't have propensity for wandering. ADM and S1 stated the building R1 was at, has delayed egress. ADM stated the doors make an audible sound and a sound stating the door had been activated, via the walkie talkie. ADM stated R1 exited thru the delayed egress. ADM stated the staff went to investigate. ADM stated staff stated the door alarm was not heard by the staff. ADM stated the staff went and deactivated the door. ADM and S1 stated the staff did not follow the protocol and do a head count after the door alarm activated. ADM and S1 stated the elopement occurred around 4pm. ADM and S1 stated maybe by 5pm R1 was found. ADM stated and S1 stated R1 was found at St. Christopher's Church. (Based on a google maps review of the location R1 was found, R1 was 0.9 miles away from the facility). ADM stated the churchgoers contacted the R1’s family member. ADM and S1 R1’s family member brought R1 back to the facility. Page 1 Out of 2. On April 10, 2025, LPA Monter interview Witness W1. W1 stated the day of the elopement she/he received a phone call from his/her family member, at 5:24pm. W1 stated his/her family member had called him/her to tell her that R1 managed to leave the facility and was found at the St. Christopher's church. W1 stated he/she immediately called the facility to inform them. W1 called R1 who had his/her cell phone and confirmed he/she was at the church. W1 stated he/she went to the church to pick up R1. W1 stated R1 was standing with a churchgoer, who stated R1 attended the entire mass. W1 stated he/she brought R1 back to the facility. Based on a review of R1’s Physician’s Report, dated February 21, 2025, R1 has a neurocognitive disorder. The physician’s report also states R1 has wandering behavior. The Department reviewed R1’ s Needs & Services Plan (ANS) dated March 5, 2025. The ANS states that one of R1’s Needs/Problem is including wandering. Furthermore, the ANS states, R1 will not leave the facility without proper supervision & staff will supervise resident and be aware of whereabouts at all times. As a result, the department issued an immediate civil penalty of $500 for absence of supervision, which resulted in R1 eloping from the facility. An additional Civil Penalty of $250 is being cited for a repeat violation, for the following code section: 87411 Personnel Requirements - General (a), which was cited during a case management visit on April 3, 2025. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Memory Care Director Evelyn Lax and a copy of the report was provided. Appeal Rights was provided. Page 2 Out of 2. END OF REPORT.