Incident investigation·September 11, 2025

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit to follow up on an incident where a resident eloped from the facility. LPA met with General Manager (GM) J.P. Rollet. LPA stated the purpose of the visit. On 7/21/2025, the Department received an Incident Report (IR) dated July 18 , 2025, stating Resident R1 had eloped from the facility at approximately 2:50PM. The IR states staff received a report from Staff S7 at approximately 2:50PM, where S7 reported ‘seeing a lady on the street that resembles one our residents.” The facility began a search for R1 and did not locate R1 in his/her room. Staff began a search in the area outside of the facility where S7 reportedly observed R1. R1 was located by facility staff at approximately 3:05PM, sitting on the side of the street across from the local fire station. R1 was being taken by paramedics for assessment due to falling and sustaining an injury to the head. Based on Google Maps search, R1 was located approximately 0.7 miles away from the facility. On 7/22/2025 and 9/11/2025, LPA Tarin interviewed Staff S1 to S6. 3 out of 6 staff did not observe R1 on the day of elopement. S1 and S4 stated he/she saw R1 in the facility between 2:45PM and 2:50PM. S6 states he/she observed R1 between 2:00PM and 2:30PM. 6 out of 6 staff stated R1 has a history of wandering behavior. 2 out of 6 staff stated R1 has eloped from the facility before 7/18/2025. S2 and S4 states R1 eloped in May 2024 but did not provide additional information. 5 out of 6 staff stated R1 has a history of cutting his/her wanderguard bracelet off. S6 did not provide additional information. LPA interviewed General Manager (GM). GM states the elopement occurred during a shift change, and "a lot of traffic was going through the front, which is the only way in and out of the community." Based on review R1’s physician’s report dated 3/27/2024, lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition is listed as confused/disoriented, has wandering behaviors, and R1 is not able to leave the facility unassisted. R1’s service plans dated 6/27/2024 states R1 has exiting seeking behavior, seeks out, loiters near or attempts to exit through doors and/or windows. R1’s Elopement Risk Assessment dated 7/13/2025 states R1 showing wandering and exit seeking behaviors, verbalize a desire to leave community/to go home, resident has a history of previous elopement. R1’s Elopement Risk Assessment also states “ Resident currently with wanderguard, However, resident have been finding ways to cut wanderguard bracelets…in the meantime will continue to replace wanderguard. LPA reviewed previous incident submitted to the Department for R1 and found an elopement that was reported on 5/17/2024, where R1 eloped from the facility on 5/11/2024 when out on a walk. R1 was returned to the facility unharmed. Based on review of R1’s hospital discharge paperwork dated 7/18/2025, R1 sustained a fractured left wrist and a closed head injury during the elopement. An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with General Manager J.P. Rollet and a copy of the report was provided. Appeal Rights were provided.