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32 | Administrator stated to LPA during visit that they were unable to follow due to other residents at the facility and believed that family lived a couple blocks away per discussion with family, so R1 would be safe. R1 was found by W1 and was taken to the Emergency Room (ER). Documentation of ER visit on 05/05/2025 was provided to LPA.
On 05/07/2025 administrator contact W1 that R1 had left the facility at approximately 10:55 a.m. and administrator confirmed they were unable to follow due to residents remaining at the facility. R1 was found by W1 at a bus stop located between W1’s residence and the facility. Following elopement R1 was taken to the Primary Care Physician (PCP), medication to assist with agitation was prescribed, documentation of new pharmacy order was provided via screen shot image of order to LPA, and confirmed by administrator during complaint interview.
On 05/10/2025 R1 was found by W1 at their residence locked in their personal vehicle. R1 attempted to contact W1 via phone call, call log noting a missed call at 3:54 a.m. and 4:28 a.m. for the date of 05/10/25 provided to LPA. W1 stated they heard a car honk around 4:00 a.m., 6:00 a.m., and the last car honk at approximately 7:00 a.m. W1 went outside and found R1 in back-seat of vehicle. W1 stated after waiting a few hours, they went to the facility at approximately 10:30 a.m. to move out R1’s personal belongings. When W1 arrived, W1 stated that staff told them R1 was still sleeping. Administrator believe that R1 was in the restroom. After stating R1 was at their home, staff allowed W1 to gather residents’ items. Interview with Administrator and staff on 06/17/2025 confirmed that elopements occurred.
On the allegation - Facility not providing medication per physician order
It was alleged that following elopement on 05/07/2025, R1 was seen by PCP who prescribed Seroquel. Image of prescription order was provided to LPA via W1. W1 stated when medication was given to facility, they stated they cannot accept residents on this medication. W1 stated that they then took the medication back and did not leave the medication with the facility so that R1 could remain. Interview conducted on 06/17/2025 with administrator confirmed that this occurred. Administrator was concerned that medication would cause R1 to be violent and unmanageable due to prior experience, Administrator was to attend next PCP appointment to discuss concerns, but discharge occurred prior to this happening. Administrator was informed by LPA that doctor’s orders must be followed. Continued on 9099-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type A
06/20/2025
Section Cited
CCR
87468.2(a)(4) | 1
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7 | 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following personal rights ...care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: | 1
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7 | Administrator will review facilities Plan of Operation that discusses elopement and dementia processes. Licensee will provide a written statement to CCL by 6/20/25 stating how they will prevent future incidents from reoccurring. |
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14 | Based on investigation interviews with Witness 1 and administrator, the licensee did not comply with the section cited above, as resident was not properly supervised which led to three elopements, which posed an immediate safety, and personal rights risk to residents in care. | 8
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Type B
06/30/2025
Section Cited
CCR
87211(a)(1)(D) | 1
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7 | 87211 Reporting Requirements (a)(1)A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified…(D) Any incident which threatens the welfare, safety or health of any resident, such as… unexplained absence of any resident. | 1
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7 | Licensee will review 87211 reporting requirements and provide CCL with a written statement of understanding. Licensee agrees to complete a Unusual Incident Report for each elopement and submit them to licensing by 06/30/2025. |
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14 | This requirement is not met as evidenced by:Based on interview and record review, facility failed to provide report of elopement incidents to Licensing as required which posed a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Request Denied
Type B
06/30/2025
Section Cited
CCR
87465(a)(4) | 1
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7 | 87465 Incidental Medical and Dental Care (a)A plan for incidental medical…care shall be developed…plan shall encourage routine medical…care and provide for assistance in obtaining such care...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: | 1
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7 | Administrator agrees to submit a written statement of understanding of CCR 87465 in its entirety. As well as review Medication guidance from the Technical Support Program. |
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14 | Based on interview and record review, Resident 1(R1) did not received medication ordered by physician which posed a potential health, safety or personal rights risk to persons in care. | 8
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