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32 | LPA reviewed R1’s resident file and observed R1’s physician report dated 10/01/2024. LPA observed that the physician report indicated that R1 was not able to leave the facility without assistance. While reviewing the physician report LPA observed out of date information that did not accurately reflect R1’s changes in condition since the report was created. LPA notified the Administrator that Community Care Licensing Division (CCLD) is requesting that the Administrator obtain an updated physician’s report (LIC 602A 4/25) for R1. The Administrator agreed to obtain the report and to send a copy to CCLD once obtained. During the physical plant tour LPA observed the living room sliding door, bedroom #3, R1’s bedroom, and the front gate to the facility to be missing auditory alarms or to have auditory alarms that were not sufficiently audible to notify staff members when the entrance was utilized. LPA informed the Administrator that that the facility must have an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement. The Administrator expressed understanding and installed new functioning auditory alarms on the living room sliding door, bedroom #3, and R1’s bedroom at the time of the visit. LPA interviewed R1 who stated that staff treat them well and activities are offered to them at the facility. R1 expressed that they prefer to walk around the neighborhood on their own and don’t always have staff assist. LPA interviewed staff members who stated that they are aware that R1 can not leave the facility without staff assistance. Staff stated that they offer to take R1 out on walks throughout the neighborhood multiple times a day but R1 does not always accept the offer. Both staff members interviewed were unaware that R1 had left the facility without assistance on 04/03/2026. LPA interviewed the Administrator who stated that they were aware of the elopement behavior that R1 expresses but were unaware that R1 had left the facility without supervision on 04/03/2026. The Administrator stated that facility staff are trained to offer R1 walks throughout the day and R1 is offered a wide variety of activities to cultivate their interests including: pet therapy, art projects, current event discussion, religious support, and various household activities. The Administrator stated that they understood their role and responsibility for ensuring adequate supervision of R1 and agreed to have R1 re-evaluated and to implement timed checks on R1’s wellbeing throughout the day. Based on the interviews conducted, evidence submitted, and file review, there is sufficient evidence to support to the allegation of “Staff did not prevent resident in care from leaving the facility without supervision.” Therefore, the allegation is deemed Substantiated at this time.
The following deficiencies were cited (Refer to LIC 9099D). Exit interview was conducted, a copy of the report and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/22/2026
Section Cited
HSC
1569.312(a) | 1
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7 | Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by: | 1
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7 | Administrator enabled motion tracking on their RING camera covering the front patio area. Administrator agreed to implement 30-minute checks by facility staff on R1 and to log the checks to ensure completion. Administrator agreed to have R1 re-assessed by their physician |
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14 | Based on interviews, evidence provided, and file review, the licensee did not comply with the section cited above as on 04/03/2026 R1 left the facility without staff assistance which posed a potential health and safety risk to residents in care. | 8
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14 | Administrator agreed to submit 1 week of 30 minute check logs and the physician's updated assessment to CCLD no later than POC due date. |
Type B
04/22/2026
Section Cited
CCR
87705(d) | 1
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7 | 87705 Care of Persons with Dementia
(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates...
This requirement is not met as evidenced by: | 1
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7 | Administrator installed functioning auditory alarms on all identified exits except the front gate at the time of the visit. Administrator agreed to conduct training with all staff shifts on the importance of responding to auditory alerts throughout the facility. |
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14 | Based on observation the licensee did not comply with the section cited above as the living room sliding door, bedroom #3, R1's room, and the front gate of the facility were missing properly functioning auditory alarms which posed a potential safety risk to residents in care. | 8
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14 | Administrator agreed to submit proof of completed training and installed front gate alarm to CCLD no later than the POC due date. |