complaint·January 3, 2023

ambulatory. Previously, R1 had eloped from the facility on 04/08/2022. Following the 04/08/2022 elopement, staff had completed a new needs and service assessment for R1 identifying the need for additional supervision, including hourly checks. Then on 06/09/2022, R1's second elopement occurred, when R1 exited the building through an emergency exit around 05:00AM. Interview revealed that the elopement occurred just after staff had conducted their hourly checks and had recently observed R1 in their room. Staff were alerted by a door alarm, but were unable to locate R1 in or around the facility grounds. R1 was returned to the facility by the police at 08:20AM. Interview revealed that following the first elopement, R1's family was advised of R1's need for additional supervision and R1's family had been looking for alternate facility placement for R1. R1 subsequently moved out of the facility following the second elopement incident. Record review revealed that while the facility does have a plan of operation that includes a dementia care plan, the dementia care plan on file does not address elopement. LPA advised the Administrator to amend the current dementia care plan or to file an addendum to the dementia care plan to include elopement protocols and submit to CCLD for approval. Based on record review and interview, the allegation that " Resident wandered away from the facility due to lack of supervision" is deemed SUBSTANTIATED at this time. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiency may result in civil penalties. Exit interview was conducted with Administrator Luis Gonzalez. Report was provided via email.