Based on interviews, facility staff did not conduct proper checks on R1 which resulted in R1 eloping and walking outside of the facility unassisted and without anyone noticing. Records also show that R1 fell and sustained a fracture during the time they were missing from the facility. The elements reviewed during the investigation, corroborate the allegation that staff neglect resulted in resident eloping and sustaining a fracture.

The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations (Title 22), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was provided.

***Immediate Civil Penalties are issued today in the amount of $500 due to neglect/lack of supervision that resulted in resident sustaining a fracture and for Repeat Violation of Section 87468.2(a)(4). At this time, an Enhanced Civil Penalty (ECP) determination in reference to Health and Safety Code 1569.49(f) is pending and may be assessed at a later date.***

It is alleged that resident hit their head and sustained a fracture during a fall after resident left the facility premises unsupervised. It is also alleged that staff were not aware that the resident had eloped from the facility and that there were prior concerns regarding safety due to resident having wandering behavior and staff being insufficient in numbers to provide supervision.

Interviews with S1-S4 revealed that R1 eloped from the facility during the overnight (NOC) shift on 10/30/2025. Staff indicated that R1 was discovered to be missing from their room during morning medication pass at around 7:00 a.m. S2 noticed that R1 was not in their room, which was unusual because R1 is always in their room waiting for their morning medication. S2 informed management regarding R1 not being in their room, and after confirming that R1 was not signed out of the facility for an outing and after looking for R1 throughout the facility, staff realized that R1 left the facility without anyone noticing. A missing person report was filed; however, it was done until 9:00 a.m. according to police report.

Staff could not precisely indicate when R1 walked out of the facility nor how many hours passed before staff realized R1 had eloped; however, staff acknowledged that it took staff long to notice that R1 was missing because a proper check was not conducted in R1’s room on the night R1 left the facility. Staff stated that R1 should have received a “bed check” in their room, but staff did not properly check on R1. Staff indicated that there were only two staff on shift and staff probably became distracted due to responding to an incident involving another resident which activated a call to 911.

Staff indicated that R1 was never heard saying they wanted to leave nor showed signs of being an elopement risk; however, staff stated that R1 was known to wander in the hallways of the facility and needed constant re-direction. Review of R1’s Physician Report indicated that R1 could leave the facility but only with a “responsible party.” R1’s Resident Appraisal indicated that R1 tends to wander and needs to be re-directed. Furthermore, R1’s Service Plan indicated that R1’s mobility is limited and needs to be escorted to activities in the facility and in the community. Service Plan states that R1 has to get a one-time bed check at night to ensure wellness and safety. It is also stated on the plan, that R1 is not able to leave the facility unassisted and that R1 has specified Dementia.

***Continues on LIC 9099-C page 2***