complaint·August 27, 2025

The Administrator called the resident's child, their attorney in fact, about 11 AM to inquire whether the resident was at their home. The Administrator called the Tuolumne County Sheriff’s Office a little before noon to report the elopement. Staff began a search of the facility for the resident, including resident rooms, facility grounds, and perimeter of the facility. The Administrator and facility staff joined the SARs teams with the search of the surrounding area, including the neighborhood adjacent to the facility up the hill, as the resident’s friend and child currently live there. The Administrator reviewed video footage from a nearby business and church. The resident was found by a SAR team on Sunday evening 8/24/2025 located in bushes down a ravine. The Administrator rode with the resident in the ambulance to the hospital. The Administrator stated that the resident had no injuries, but was dehydrated. The resident was released from the local hospital on Monday 8/25/2025 about 3:30 AM and returned to the facility. The resident and their spouse moved into a new unit in Memory Care that same day. The LPAs reviewed the resident’s service plan dated 11/22/2024. The LPAs observed that the plan included the goal that the resident had a “History of wandering outside the community…Health and safety may be jeopardized.” The resident was reappraised after the 8/23/2025 elopement to ensure that their current service plan addressed the resident’s recent wandering. The resident’s new plan dated 8/26/2025 includes the same goal with the same language as the 11/22/2024 plan in regard to wandering. The LPAs reviewed the resident’s LIC 602A Physician’s Report for Residential Care Facilities for the Elderly (RCFE), signed by a physician on 1/6/2025. The report stated on page 4 that the resident was “Able to leave the facility unassisted.” This report does not reflect the information contained in the service plan written a month and a half before. The 1/6/2025 LIC 602A was based on the resident’s last exam, which was in late September 2024, prior to the completion of the resident’s service plan in November 2024. The resident was diagnosed with dementia and epilepsy, according to the LIC 602. No documentation was available to suggest that the resident’s physician was notified of the wandering behavior identified in their November 2024 service plan. This deficiency will be addressed in a separate report. The LPAs noted that the resident’s file did not contain an elopement risk assessment prior to the resident’s recent elopement on 8/23/2025. Health and Safety Code Section 1569.312(d) states that facility staff must remain “aware of the resident's general whereabouts, although the resident may travel independently in the community.” Additionally, 22 CCR Section 87705(e)(5) states that “Facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility…” This facility is hereby cited per 22 CCR Section 87705(e)(5). Due to a violation involving a lack of supervision of a resident, a civil penalty in the amount of $500 is hereby assessed. The licensee was informed that a civil penalty assessment based on Health and Safety Code Section 1569.49(f) is currently under review and may be assessed at a later date. Once this has been determined, CCLD personnel will return to assess the civil penalty, if necessary. An exit interview was held. Appeal rights and a copy of this report were left with Pais.