Complaint Investigation Report

Resident interviews revealed that R1 did not know how they were able to leave and could not identify the person(s) who helped them elope from the facility. R2 stated they were not with R1 the day of the incident. This corroborates that staff were not aware of R1's location or whom they were with.

Outside Source Interviews revealed that when S1 was asked how R1 was able to leave memory care, that it was possible "R1 left while another resident was moving into memory care."

Records review revealed that R1 requires a "secured Memory care due to the diagnosis of dementia and serious cognitive impairment with a history of wandering and exit seeking behavior." Per the general absentee notification plan for all residents, staff are to notify police within 30 minutes of elopement if the resident is not located. Staff were unable to follow the absentee notification plan due to lack of knowledge of resident's absence. Records review corroborated the need of supervision for R1.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Cathy Allen, Executive Director, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.