Complaint·September 17, 2024

Facility staff did not observe resident was missing from the facility: On 5/21/2024, resident R1 was found at the neighborhood of the facility and Police was called. Police officers found R1 was wearing a bracelet which shows the address of the facility. R1 was brought back to the facility by the Police Officers. On 5/31/2024, LPA interviewed Administrator (ADM). ADM stated on 5/21/2024 morning, resident R1 was in and out the facility main entrance door. ADM stated staff S1 was accompanying with R1, and then S1 took R1 for walking to the near by park. Around 11:30AM, S1 brought R1 back to the facility and R1 took a break at the bedroom. ADM stated S1 started to prepare lunch. ADM stated around 12:30PM, police officers brought R1 back to the facility and the police officers stated R1 was found at the neighborhood. ADM stated he/she and staff did not hear the door alarm sounding. LPA checked the exit door of R1's bedroom, the alarm sounded when LPA and ADM opened the exit door of R1's bed room.. LPA interviewed resident R1. R1 can tell his/her name and DOB. R1 was unable to say what is the year today. R1 stated he/she likes to live in the facility. R1 cannot remember if he/she eloped from the facility recently. LPA interviewed resident R2. R2 was able to tell his/her name and DOB. R2 can tell what is the year today. R2 stated he/she knows a resident eloped from the facility recently, but he/she cannot remember what is the date and detail. LPA interviewed staff S1. S1 stated on 5/21/2024, around 11:00AM he/she took resident R1 to walk to the near by park. S1 stated around 11:30AM, he/she took R1 back to the facility and let R1 stay in the bedroom to take a break. S1 stated he/she then started to prepare the lunch. S1 stated R1 was brought back to the facility by police officers. S1 stated he/she checked R1's body and did not find any wound or bruise. S1 stated staff gave water and lunch to R1. S1 stated R1 is fine after back to normal. Continue on LIC9099-C. Page 2 of 3. LPA interviewed staff S2. S2 stated he/she was off when the incident occurred. S2 stated he/she knew the incident on the next day that R1 eloped from the facility. S2 stated during the incident, staff S1, another staff S3, Administrator and licensee were at the facility. S2 stated police officers brought R1 back to the facility. LPA interviewed licensee (LCN). LCN stated on 5/21/2024, he/she was working/cleaning at the backyard. LCN stated around 12:30PM the police officers brought R1 back to the facility. LPA reviewed R1's IPP dated 6/08/2023, page 5, it specifies R1 has a history of wandering/AWOL behavior. LPA reviewed R1's physician report dated 1/24/2024, it specifies R1's cognitive abilities are in a conditional state between normal aging and cognitive impairment, and R1 has history of AWOL. LPA reviewed R1's Appraisal/Needs and Services Plan dated 5/10/2024, it specifies R1 needs to desist from leaving the facility without notice at all times, day and night. R1 needs to be supervised at all time. Based on the interviews and records reviewed, the facility did not report R1's elopement incident to CCL office, the facility did not ensure resident R1 received supervision to meet R1's care need. The Department has investigated the above allegation. Based on documents reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED . Citations were noted today. Please see LIC9099-D. Appeal right was provided. Exit interview was conducted with ADM. A copy of the report was provide to ADM. Page 3 of 3.