Interview with Executive Director (ED), Valeria Garcia, revealed that R1 did elope from the facility noting it was before her start date. It was stated that it was believed R1 followed a visitor through several secured doors. ED stated that facility care staff received training on the supervision of clients in care on two recent occasions prior to R1’s elopement incident and policies were implemented. Information obtained from additional staff (S1) revealed that elopement procedures were followed once R1 was reported missing. Furthermore, S1 noted R1 was assessed for injuries and documented not observing any injuries. An interview was attempted with R1 resulting in LPA concluding interview for inadequate information.

Interview with Additional Witness 1 (AW1) revealed a primary concern regarding the ongoing lack of adequate supervision at the facility, citing constant incidents related to supervision. AW1 noted that the lack of information surrounding R1’s elopement exemplified staff failure to provide adequate supervision.

Through Records review, information obtained confirmed training regarding resident supervision was conducted on May 21, 2025 and July 3, 2025, corroborating statements made by ED. Additionally, a medical assessment dated March 25, 2025, was reviewed and revealed R1 is not capable of leaving facility unsupervised. Review of incident reports submitted to CCLD showed no documentation of preventive measures, such as redirecting the resident was conducted. The documentation reviewed identified the cause of R1’s elopement as unknown, only providing an assumption.

Regarding the allegation that staff did not report incident to appropriate parties in a timely manner, it was alleged facility staff failed to report the elopement to all proper agencies. Interview with Administrator Liliana Moreno confirmed submitting an incident report to the Community Care Licensing Division (CCLD) and the Long-Term Care Ombudsman, noting that the CCLD report was filed on July 14, 2025, and the Ombudsman report on July 15, 2025. Administrator clarified that an SOC 341 form was not completed, as it was her understanding that elopement or AWOL incidents do not meet the criteria for that report without physical harm. Liliana added that R1 was assessed with no bodily injury observed and emphasized that she believed all required documentation was submitted to the appropriate agencies in compliance with regulatory requirements. Interview with AW1 revealed that a SOC 341 Report of Dependent Adult/Elder Abuse was Abuse (SOC341) was never submitted to Long Term Care Ombudsman failing to comply reporting requirements under Neglect.

Continued on 9099-C.

A record review confirmed that a special incident report was submitted to Law Enforcement, Community Care Licensing, and the Long-Term Care Ombudsman (LTCO). Additional information obtained that an SOC 341 was not submitted to these agencies. Further research revealed the elopement incident with R1 included unknown factors that classified the incident under neglect guidelines. Contributing factors included the unknown circumstances of how R1 eloped from a secure facility, the lack of any attempted staff intervention to redirect, and the medical determination that R1 was not permitted to leave the facility unassisted.

Based on interviews and record reviews, the allegation that staff did not prevent resident in care from leaving the facility unsupervised and staff did not report incident to appropriate parties in a timely manner is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. This is a potential risk to clients in care. The facility will be cited.

An exit interview was conducted. A copy of this report was provided to Executive Director Valeria Garcia, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights were provided.