Incident investigation·April 4, 2025

Licensing Program Analysts (LPAs) Marcella Tarin and Manuel Monter arrived unannounced to conduct a Case Management-Incident regarding 2 elopements that occurred on 12/8/2024 and 12/15/2024. LPAs met with Administrator Candace Bolin and stated the purpose of the visit. Elopement 12/8/2024 On 12/11/2024 the Department received an incident report for Resident R1, who eloped from the facility on 12/8/2024. The incident report stated: "Door 1 alarmed at 11:11 AM, Care giver looked out the window of Garden house and saw the resident walking outside. Staff Went out to escort resident back inside and the resident was no longer in site. Staff immediately initiated a search of the surrounding neighborhood...911 was called and police assisted with search...Police escorted resident back to the community at 12:20 PM. Police officer reports that the resident walked in the police station." On 12/11/2024 LPA Simi Rai spoke with ADM regarding the incident report of R1's elopement on 12/8/2024. ADM stated that the whole building has delayed egress doors except for one door, which R1 found and exited the facility from during the incident. ADM stated the door located on the main floor in the stairwell had an alarm and not a delayed egress. The facility has four floors with the memory care unit is the in the basement. ADM stated R1 has neurocognitive disorder. ADM stated R1 cannot leave the facility unassisted. R1 was found by the police when R1 entered the police department down the street from the facility. Based on a Google Maps search the Police Department is located 0.4 miles from the facility Page 1 of 3. On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM stated R1 does not have exit seeking behaviors and no history of wandering. ADM stated R1 has not expressed he/she wants to leave the facility, and resident does not have recollection of leaving the facility. LPAs Marcella Tarin and Kenneth Madrigal interviewed staff, S1-S2. Staff S1 stated, R1 often shows wandering behavior by the front door. S1 stated every day, R1 by the door looking out the door wanting to leave. On 2/20/2024 LPAs Marcella Tarin and Manuel Monter interviewed 11 staff (S3-S13). 6 out of 11 (S3-S6, S12, S13) staff stated R1 has wandering behaviors. 5 out of 11 (S7-S11) staff stated he/she does not know if R1 has wandering behaviors. Based on review of R1's service plan dated 12/06/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 5/9/2024 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted. Elopement 12/15/2024 On 12/18/2024, the Department received an Incident Report regarding Resident R2 eloping from the facility on 12/5/2024. R2 was returned to the facility by local police that same day and was unharmed during the elopement. On 12/19/2024, LPAs Marcella Tarin and Kenneth Madrigal interviewed the Administrator (ADM). ADM states R2 wears a Wanderguard and has exit seeking behavior. ADM stated the facility was not aware R2 had eloped from the facility until police informed the facility that R2 was found at a grocery store, Trader Joes. Based on a Google Maps search, R2 was located 0.9 miles from the facility. On 2/20/2024 LPAs Marcella Tarin and Manuel interviewed Administrator (ADM) ADM stated R2 has eloped from the facility in the past but could not provide a date. Page 2 of 3. LPA’s interviewed 11 staff (S3-S13). 8 out of 11 (S3-S9, S12) staff stated R2 has wandering behaviors, and 4 out of the 8 (S7-S9, S12) staff state R2 has eloped or attempted to elope from the facility in the past. 3 out of 11 (S10, S11, S13) staff state they are not aware of R2 eloping from the facility of having wandering behaviors. Staff S6 stated the facility has a list of residents who can leave unassisted. S6 stated if a resident who can’t leave the facility unassisted tries to leave the facility, staff will redirect. Staff S6 acknowledged that resident R2 likes to come to the front door, but staff will redirect. On 4/5/2025 LPAs interviewed ADM. ADM stated staff at the front desk have a list of residents (with pictures) who can leave the facility unassisted. Based on evidence reviewed, on December 5, 2024, R2’s service plan dated 9/23/2024 under Evaluation Item, Evaluation Section: Psychosocial: Wandering, states resident has a current or history of wandering within the residence or facility and may wander outside. R1’s physician’s report dated 2/7/2023 lists R1’s diagnosis as neurocognitive disorder. R1’s mental condition as confused/disoriented, has wandering behaviors and R1 cannot leave the facility unassisted. Based on evidence reviewed, R2 walked out of the lobby’s front door by following an individual who was exiting the facility on 12/5/2024. As a result, the department issued an immediate civil penalty of $500 for an absence of supervision, which resulted in R1 and R2 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 Administrator Candace Bolin and a copy of the report was provided. Appeal Rights was provided. Page 3 of 3