Complaint Investigation Report

During the brief call, the Administrator stated that Community Care Licensing would be receiving an incident report regarding a new resident, R1, who eloped on 11/26/25 or 11/27/25; the Administrator was uncertain of the date.

The Administrator stated the elopement occurred in the early morning hours and that R1 had made it up the driveway and was just onto the parking lot area of the apartments next door, which is not part of the facility property.

LPA received a faxed LIC 624 Unusual Incident/Injury Report on 12/03/25. The Resident Services Director (RSD) was noted as the one who submitted the report, and it had the signature of the Administrator. Review of the incident report states R1 “set off [their] wanderguard pendant alarm while attempting to exit through the front doors of the community. Community staff immediately responded and intercepted the resident in the foyer between the double doors.” The incident report did not match what was discovered through the complaint investigation nor what was reported during the phone discussion by the Administrator. The investigation also revealed the facility called Emergency Medical Services (EMS) due to R1’s behaviors, hallucinations and refusal to return to R1’s room.

LPA reviewed the electronic health record (eHR) for R1 for the date of the incident, which stated R1 “wanderguard pendant went off by room 137 door. Medication Technician…went to check door. Resident was seen outside of community.” Additional note stated “…spotted resident far away from the community in front of another building…” An image of room 137’s location next to the side door was taken by LPA on 12/08/25 to confirm the location was not near the “front door.”

LPA obtained a copy of the EMS report, which states: “Per staff on scene, Pt was wandering outside of the facility.” This also contradicts the initial report that “Community staff immediately responded and intercepted the resident in the foyer between the double doors.”

During the visit on 12/11/25, an interview with RSD was conducted for another open complaint, but during interview LPA inquired about elopement incident. RSD’s account matched the events noted in the eHR. LPA asked RSD to explain why their interview did not match the LIC 624 Unusual Incident Report sent to LPA on 12/3/25; RSD was unsure. Prior to leaving, the Administrator stated that the RSD admitted copying an updated narrative from their regional office into the incident report and did not review what the update was.