Incident investigation·November 12, 2024

On 11/12/2024, Licensing Program Analyst (LPA) Kiran Jain conducted an unannounced case management visit to follow up regarding an incident that occurred on 11/04/2024 where resident (R1) eloped from the facility after attending a birthday concert at the facility’s great room. LPA Jain met with Executive Director, Li Li and explained the purpose of the visit. On 11/04/2024, R1 eloped from the facility around 3:35 PM during a birthday concert unsupervised. R1 was observed to be eating cake in the great room around 3:30 PM. R1 was stopped by the owner of a martial arts studio down the street from the facility and the studio owner called 911. EMT called the facility to let them know on R1’s condition and location. Based on the interview conducted with Executive Director (ED), ED stated R1 was at a birthday party celebration in the great room from 2:30 PM to 3:30 PM and there were about 20 residents, and 2 activities assistant staff members present during the birthday concert event. After the event, R1 got up and walked back to their room on their own. R1 then came back out to the living room from their room and wandered out by walking out of the front door of the facility without notifying anyone. No one witnessed that. R1 walked into a local shop and said that they are local and are very tired. Shop owner was surprised to see an elderly in distress breathing heavily and called 911. EMT called facility to notify about R1’s location. Facility staff members went down the street to pick up R1. When staff arrived, R1 was sitting on a bench and answering questions with EMTs. Staff members recommended to send R1 to the Hospital for further evaluation and observations. ED stated R1 is high functioning, walks with a walker, never showed any wander behaviors prior to the incident. ED stated that R1 is part of Elite care in Assisted Living, where there are 7 staff members to take care of 24 residents. Based on the review of R1’s Physician’s Report (LIC 602) dated 06/08/2023, R1 has a primary diagnosis of Dementia, is non-ambulatory due to mental condition and deemed not able to leave the facility unassisted. The facility staff failed to ensure that R1 doesn’t leave the facility unassisted, which posed an immediate health, safety or personal rights risk to persons in care. Based on the review of R1’s Resident Assessment Results done on 03/01/2024, R1 needs to be provided staff escort to and from the activities. The facility staff failed to ensure R1 is provided escort after attending an activity inside the facility, which posed an immediate health, safety or personal rights risk to persons in care. LPA Jain conducted additional staff interview with S1 and reviewed additional documents - R1’s Progress notes, Activity Staff schedules, and in service all staff training for Elopement policy and procedures. A deficiency was cited under the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. See LIC 809-D page for more information. An immediate civil penalty of $500.00 was assessed today for the Absence of Supervision, which resulted in R1’s eloping from the facility. Failure to correct the deficiency may result in additional civil penalties. This report was reviewed with Executive Director, Li Li and a copy of this report along with the appeal rights was provided. A copy of the civil penalty was also provided.