Incident investigation·April 21, 2025

Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Incident visit, The purpose of the visit is to follow up on an elopement Incident reported to the LPA on 04/15/25. The LPA met with staff and the reason for the visit was explained. Administrator Roberto Dela Vega arrived at 4:05 p.m. It was reported that on 04/11/2025, at approximately 4:00 a.m. when facility staff was getting ready to prepare breakfast and clean up they found out that Resident #1 (R1) was not in their bed. Staff searched for R1 and could not find them, they reported to the Administrator and police. Police notified the Administrator that the resident had been found and was at St. John's hospital. The Administrator brought R1 back to the home around 5:30 a.m. On 04/18/25, the LPA conducted a phone interview with Administrator Roberto and requested hospital discharge documents. During the phone call, the Administrator revealed that R1 had sustained a bruise in the left eyebrow. On 04/20/25, the LPA received R1's hospital discharge documents, and a photo of R1's face. Discharge documents revealed that R1 had sustained a fall, and discharge diagnosis were listed as" closed head injury, nasal bone fracture and facial laceration. Photo of R1 showed R1's face, with a stitched laceration above their left eye, and yellow and purple discoloration around both cheek bones. During today's visit the LPA interviewed R1, two staff and the administrator. R1 was not able to fully explain what happened to them, however they revealed they feel safe at the home. Both staff revealed that R1, had exhibited wandering and elopement behaviors prior to R1's elopement. Report will continue on LIC809-C, 2nd page. Staff further revealed that R1's prior roommate had stated to the police they went to the restroom at 1:00 a.m. and they did not see R1 in the room. Staff also revealed that even though they have auditory alarms on the doors, they cannot hear them when they are in a deep sleep and the last time they checked on R1 was at 10:30 p.m. Hospital records indicate that R1 was at the hospital on April 10, 2025 23:11 PDT. Pursuant to Title 22 of CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, today's reports and appeal rights were reviewed and issued to Administrator Roberto Dela Vega.