Incident investigation·May 20, 2025

Licensing Program Analyst (LPA) Alviso conducted a case management- incident inspection, on 5/20/25 at approximately 3:30pm, and met with Administrator Megan Leone, and Heath Services Director Michelle Simpson.LPA is conducting a case management to obtain more information on a resident AWOL incident that was reported by the Administrator. LPA reviewed resident (R1's) records. On the day the resident (R1) had eloped there was a move-in, and the alarms on the exit door had been turned off. R1 had eloped/AWOL from the memory care unit without staff's knowledge and/or supervision. R1 had a fall when eloping the facility, and was found on the floor outside. R1 had a skin tear on their elbow and abrasion to their eyebrow. Staff provided first aid, and 911 was called as a precaution. R1 was cleared to remain in the facility after assessment by 911 responders. LPA requested copies of specific resident records. LPA requested copies of the AWOL/Elopement training's provided to the staff, and the revised "door security checklist" implemented in the memory care unit. Copies were provided to the LPA. Following deficiency will be cited: The deficiency will be cited, 87705(d) Care of Persons with Dementia - The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions, see LIC809D. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Maria Cortes. Appeal Rights Provided to the Administrator.