374604545-2-21-2025-08-AS-LTEZ-DF8W2F-20250329165417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604545
Report Date: 02/21/2025
Date Signed: 02/21/2025 04:52:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2024 and conducted by Evaluator Nacole Patterson

COMPLAINT CONTROL NUMBER: 08-AS-20241211132531

FACILITY NAME:	GARDENS AT ESCONDIDO		FACILITY NUMBER:	374604545
ADMINISTRATOR:	MCBRIDE, FERLINA		FACILITY TYPE:	740
ADDRESS:	1342 NORTH ESCONDIDO BLVD		TELEPHONE:	(760) 480-8155
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	101	CENSUS: 69	DATE:	02/21/2025
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director Angela Scott-Kapiloff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Lack of supervision resulted in resident elopement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Angela Scott-Kapiloff.

On 12/11/24 it was alleged that the Licensee's lack of supervision for Resident 1 (R1) resulted in R1 eloping from the facility. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review. Staff interviews consistently showed that R1 was almost completely independent and lived in the Assisted Living section of the building. The interviews did not corroborate that staff provided less supervision than was necessary for R1, as interviews showed that staff were aware that R1 was not able to leave the building unassisted, and redirected R1 when R1 attempted to leave by themselves earlier the day of the incident. Interviews revealed that staff were unaware that R1 came back downstairs later in the day and exited the facility through a door other than the front entrance. (Continued on LIC9099-C p. 2)

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241211132531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDENS AT ESCONDIDO	FACILITY NUMBER: 374604545
	VISIT DATE: 02/21/2025

NARRATIVE

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(Continued from LIC9099 p.1)

Staff interviews revealed that the elopement was a new behavior for R1, as they were noted to be a low elopement risk and had not attempted to leave the facility unassisted before this incident. Staff interviews additionally revealed that the Licensee adjusted R1's supervision level after the incident by implementing alert charting (status checks with documentation) and escorting R1 to all events. The interviews revealed that staff provided the level of supervision consistent with R1's care plan, R1 experienced a change in condition by eloping for the first time, and the Licensee immediately adjusted the care level/supervision provided to R1 after the incident.

R1 was interviewed regarding the incident. R1 was not able to recall why they left the facility or which door they exited through. R1 was only able to recall the events after the incident occurred.

Outside source interviews did not refute or corroborate the allegation. Attempts were made to contact the party who assisted R1 in the community after the elopement, but the source did not respond to inquiries. A second outside source familiar with the facility was contacted and confirmed being aware of the incident. However, this source did not conduct an investigation or pursue any additional information regarding the incident.

Review of facility and outside source records confirmed staff statements that while R1 was not allowed to leave the building unassisted, they were not a wandering risk. R1's Elopement Risk Assessments show that R1 was a low wandering risk. R1's Needs and Services Plan, as well as an acuity assessment, showed that R1 was completely independent, with the exception of being provided reminders for bathing, using their walker and attending activities. Charting Notes for R1 were absent of any elopement or wandering incidents for R1 prior to this event. The charting notes showed that the Licensee increased their assistance/supervision to R1 after the incident; R1 was placed on alert charting and escorted to all events after the incident. Records showed that R1 explicitly requested less supervision from staff by signing a waiver not to receive checks at night.

During two unannounced facility visits, LPA directly observed all facility exits. LPA observed the exits for Assisted Living to be consistent with the needs and supervision level for independent Assisted Living residents.

(Continued on LIC9099-C p.3)

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20241211132531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GARDENS AT ESCONDIDO	FACILITY NUMBER: 374604545
	VISIT DATE: 02/21/2025

NARRATIVE

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(Continued from LIC9099-C p.2)

The information gathered during the investigation did not show that the Licensee provided inadequate supervision to R1, resulting in the elopement. The evidence shows that R1 did not have a history of elopement behaviors and experienced a change in condition, and that the facility immediately adjusted the care plan to accommodate.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED. An exit interview was conducted with Executive Director Angela Scott-Kapiloff, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Nacole Patterson
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC9099 (FAS) - (06/04)

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