Facility Evaluation Report

On 4/3/2025, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced case management visit regarding an Unusual Incident/Injury Report (LIC 624) submitted by the facility reporting Resident 1 (R1) eloped from the facility on 3/30/2025. LPA met with Administrator, Jolene Farish and Memory Care Director (MCD), Lorena Vivar who were informed of the purpose of the visit.

LPA conducted an interview with Administrator Farish and MCD Vivar and both reported the following information. On 3/30/2025 at approximately 6:00 a.m., Resident 2 pulled the fire alarm disarming all exit doors, which were secured with electric magnetic lock systems. At the time, all residents were accounted for and caregivers assessed and secured all exit doors except the courtyard gate. The doors leading to the courtyard gate were not disarmed as they require a keyed entry and were locked when the fire alarm was pulled. As a result, caregivers reportedly overlooked/failed to ensure the courtyard gate was secured.

At approximately 5:30 p.m., Staff 1 went to R1's room to check on them but was unable to locate them. Staff conducted a thorough search of the facility but were unable to locate R1. Staff found the courtyard gate closed but unsecured. The facility notified local law enforcement and R1's responsible person. Caregivers reported last seeing R1 at approximately 5:00 p.m. At approximately 8:00 p.m., R1 was returned to the facility by law enforcement. Upon arrival, R1 was assessed and no visible injuries were noted. LPA reviewed R1's Physician's Report (LIC 602A) dated 7/25/2024 noting R1 is unable to leave the facility unassisted.