Cadence at Rancho Cucamonga

Allegation investigated: Staff do not ensure residents' rooms are free of hazards Staff do not provide adequate supervision, resulting in resident eloping Staff falsify medication records Staff do not safeguard residents' medications Staff store feces in freezer designated for residents' supplemental nutrition Staff leave medication unsecured and accessible to residents Unqualified staff is giving injections to resident Staff retaliates against whisteblower

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Willett and explained the elements of the complaint. Allegation #1 - LPA Prieto toured facility with Executive Director Ashley Willett (S1) and interviewed resident #1 (R1), in question. R1's room was clean and free from obstructions. R1 made admission that she has refused cleaning from staff when they arrive for services. This causing an unsafe environment in her room, but by her own accord. Allegation #2 LPA interviewed R2 at the facility and states that he is aware of his surroundings. Facility staff conducts safety checks every 2 hours, is monitored when approaching facility exits and wears a tracking device. R2 resides in the Assisted Living section of the facility and can leave the facility with the assistance of facility transport. Unsubstantiated Allegation #3 - LPA interviewed Medication staff #2 (S2) relating to records being falsified by staff. LPA, along with Memory Care Director (S3), review R3 medical records and found them to be complete and accurate. Allegation #4 - LPA interviewed Medication staff #2 (S2), along with Memory Care Director (S3), relating to resident's medications not being safeguarded. LPA made observations that medications are locked with Medication staff holding the only key for access. Allegation #5 - LPA addressed the allegation that feces are stored in the freezer designed for resident's supplemental nutrition. LPA toured facility kitchen and did not find any evidence related to this allegation. LPA tour Assisted Living Med Tech room and did not find any evidence related to this allegation. LPA toured Memory Ward Med Tech room and did not find any evidence related to this allegation. Memory Care Director stated that they did have one resident who had doctor's orders to gather fecal samples related to a medical condition. These samples were collected with appropriate medical containers, sealed and placed in a seal bio medical bag and stored in an designated freezer storage for this type of collection. S1 states that nutritional supplement drinks are not stored in a freezer. Allegation #6 - LPA interviewed Medication staff (S2), along with Memory Care Director (S3), relating to resident's medications not being secured and accessible to residents. LPA made observations that medications are locked with Medication staff holding the only key for access. Allegation #7 - LPA interviewed Medication staff (S2), along with Memory Care Director (S3), relating to unqualified staff giving injections to residents. Records reveal the resident in question does receive injections weekly by a Home Health professional and not by facility staff. LPA observed this medication and orders and found them to be correct. Allegation #8 - LPA interviewed Executive Director who states an internal investigation was conducted by corporate management and no supporting evidence was found of retaliation. Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Willett and a copy was left with the facility.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 56-AS-20260723080335

Allegation investigated: Staff forced resident to remain seated in a wheelchair

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Executive Director Willett and explained the elements of the complaint. Allegation #1 - LPA interviewed resident #1 (R1), in question, at the facility. R1 was in a wheelchair at the time of interview and without restraints to that wheelchair. R1 states that she can, and is able to, walk throughout the ward on her own as she wants to. R1 was asked if staff confine her to the wheelchair. R1stated they do not. LPA interviewed Executive Director (S1) who stated that R1 is assessed as a fall risk and is ambulatory, but does require moderate assistance by staff when walking throughout the facility. S1 states R1 has moderate assistance with toileting and grooming and independent in other task such as meal consumption. LPA tour outside courtyard to see that it was free from any obstructions that would cause interference with Unsubstantiated a resident's mobility that would cause a possible fall. LPA toured the ward's corridors and found them to be free from onstructions. LPA asked S1 if R1 has ever been restrained to her wheelchair to keep her from possible falls. S1 stated that R1 has not. LPA asked S1 if she instructed staff at the Memory Ward to have R1 remain in her wheelchair for the fear of falling. S1 stated that she has not. LPA interviewed Memory Care Director (S2) regarding the assessment of R1. S2 produced her latest assessment indicating R1 is a fall risk and requires with moderate assistance toileting and bathing. LPA asked if the wheelchair that R1 uses is required for mobility. S2 stated that R1 was recently placed on Hospice and the chair was issued by the Hospice agency, but is not required for total mobility. S2 states that R1 is independent with her mobility, but staff assist by walking beside R1. LPA asked S2 if she has forced R1, or asked staff, to have R1 sit in her wheelchair restricting her from walking? S2 states no. Based on the information obtained there is not enough evidence that staff forced resident to remain seated in a wheelchair. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Willet and a copy was with the facility.the state’s words, verbatim · CDSS document, Jun 1, 2026 · control 56-AS-20260526130412

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to have Executive Director Ashley Willett sign amended complaint report ( 56-AS-20260305170652 ). This report signed by Executive Director Willett and LPA Prietothe state’s words, verbatim · CDSS document, Mar 12, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Ashley Willett and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (117) current census (110). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med-Room office inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed eight (8) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Ashley Willett.the state’s words, verbatim · CDSS document, Feb 25, 2026

Allegation investigated: Facility staff handled residents in a rough manner. Facility staff yelled at residents. Facility staff did not meet residents' incontinence care needs. Facility staff did not ensure residents had clean bed sheets. Resident sustained an unexplained injury in care. Resident not accorded dignity in personal relationships with staff. Facility staff did not ensure residents were regularly observed for changes in functioning. Facility did not meet night supervision requirements.

On 2/24/2026, Licensing Program Analyst (LPA) Beena Singh arrived at the facility to deliver investigative findings. LPA met with Facility Executive Director Ashley Willett and explained the purpose of the visit regarding the allegation stated above. Investigation was conducted by LPA Singh, which included LPAs observation, Interviews and review of records and walk through of the facility. First Allegation: Facility staff handled residents in a rough manner. Seven(7) out Seven(7) residents stated that they have not/been mishandled by the staff in a rough manner. Five (5) out of Five (5) facility staff stated that staff never handles residents in a rough manner and always being careful due to residents are vulnerable and fragile and staff always have in-services to train all staff regularly. Unsubstantiated Second Allegation: Facility staff yelled at residents. Seven(7) out of Seven (7) residents stated that facility staff have never yelled at the residents and are always helpful and kind to them. Five (5) out of Five (5) facility staff stated that staff never yelled at residents, they do speak loud sometime due to some residents hearing issues but never yelled at the residents in care. Third Allegation: Facility staff did not meet residents' incontinence care needs. Seven(7) out of Seven (7) residents stated that facility staff has always met residents’ incontinent care needs. Five (5) out of Five (5) facility staff stated that staff did meet residents' incontinence care needs and assist residents in daily activities of living. Fourth Allegation: Facility staff did not ensure residents had clean bed sheets. Seven(7) out of Seven (7) residents stated that facility staff always ensure that residents have clean bed sheets. Five (5) out of Five (5) facility staff stated that staff did ensure that residents have clean bed sheets and linen and change it weekly or as needed. Fifth Allegation: Resident sustained an unexplained injury in care. Seven(7) out of Seven (7) residents interviewed reported having no knowledge of the specific individual who sustained an unexplained injury while under the care of staff. Five (5) out of Five (5) facility staff stated that residents are being looked after well and staff contact emergency services whenever a resident is injured or requires immediate assistance. Residents expressed a consistent belief in the facility’s safety procedures, noting that staff members reliably contact emergency services whenever a resident is injured or requires immediate assistance. Sixth Allegation: Resident not accorded dignity in personal relationships with staff. Seven(7) out of Seven (7) reported that facility staff consistently maintain high professional standards. These residents characterized their interactions with the staff as being defined by dignity, respect, and a genuine commitment to quality care. Five (5) out of Five (5) facility staff stated that it never happened that any resident not accorded dignity in personal relationships with staff. Seventh Allegation: Facility staff did not ensure residents were regularly observed for changes in functioning. Seven(7) out of Seven (7) residents stated that according to a recent report, 80% of residents confirmed that facility staff maintain consistent oversight regarding their well-being. The residents stated that employees effectively monitor them for any changes in physical or mental functioning, as well as shifts in their overall medical conditions. A significant majority of residents feel actively monitored. Staff are recognized for identifying fluctuations in resident health. Five (5) out of Five (5) facility staff stated facility staff always ensure residents were regularly observed for changes in functioning. Eighth Allegation: Facility did not meet night supervision requirements. Seven(7) out of Seven (7) residents stated that facility staff do meet night supervision requirements and Staff stated that there are enough staff for NOC Shift and there is one staff who is on call and Staff check on residents during the night. LPA reviewed records which shows there are enough staff for the night supervision and to take care of the residents at night shift. Based on the information obtained there is not enough evidence that staff are not following COVID protocol, staff are not meeting the needs of COVID Positive residents, residents are not being served meals in a timely manner due insufficient staffing, residents are not being assisted with feeding in a timely manor due to insufficient staffing, residents are not being assisted with toileting in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted where this report LIC9099 was discussed, and a copy of the report was provided to the Facility Executive Director Ashley Willett at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 24, 2026 · control 56-AS-20231117122336

Allegation investigated: Staff did not seek timely medical attention for resident's serious injury. Staff refused to assist resident with toileting. Staff refused to assist resident with dressing.

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Facility Administrator Ashley Willett and explained the purpose of the visit regarding the allegation stated above. First allegation: Staff did not seek timely medical attention for residents’ serious injury. Investigation was conducted by department staff which included review of records and witness interviews. R#1 Physician Report indicates that R#1 was diagnosed with Osteoporosis disorder, a disorder that is an increased risk of fractures. Based on R#1 records which revealed that R#1 had a history of Osteoporosis the facility should have provided immediate medical attention by transporting R#1 to a local hospital after the injury was reported and discovered. Based on R#1 record it was discovered that R#1 injury was found on March 2, 2023. However, R#1 did not receive an X-ray until March 4,2023 and six days later March 7,2023 R#1 had a splint applied. Second allegation: Staff refused to assist resident with toileting. Substantiated Regarding the allegation “Staff refused to assist resident with toileting” the department received photo evidence of Resident #2 which demonstrated R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist. In addition, photo also demonstrated R#2 blanket to be sitting on the floor next to a used diaper. Third allegation: Staff refused to assist resident with dressing. Regarding the allegation “Staff refused to assist resident with dressing” During the observation of photo evidence pertaining to Resident #2 LPA observed R#2 lying in bed uncovered wearing only a diaper brief that went down below R#2 waist and exposing resident. Photo demonstrated R#2 in a curled-up position undressed and without covers and or blankets. Based on the evidence gathered during the investigation, the above allegations are Substantiated. A finding that the complaint is Substantiated means that the findings are valid because the preponderance of the evidence standard has been met. Title 22 regulations 87465(2), Incidental Medical and Dental Care, 87468.1 Personal Rights of Residents in All Facilities (a)(1)(2) & (3), from division 6, chapter, article 6, is, being cited on the attached LIC 9099 D. In addition, an immediate civil penalty of $500.00 was assessed, according to the Health and Safety Code 1548 (c). Furthermore, an additional civil penalty may be imposed by the Health and Safety Code 1569.49 (f). An exit interview was conducted where this report, appeal rights, and LIC9099-D was discussed, and a copy of the report was provided to the Facility Administrator at the conclusion of the visit. Regarding the allegation “Staff handled resident in a rough manner causing injury. LPA conducted a review of record upon the review of records LPA discovered that Resident#1 did not indicate to staff or report to staff that resident’s injury was caused by staff or that staff had handled R#1 in a rough manner causing an injury. In addition, LPA discovered that based on interviews R#1 reported the injury to staff. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with residents and all denied being handled in a rough manner by staff. In addition, all residents also denied witnessing staff handling residents in a rough manner. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied handling residents in a rough manner. In addition, S#2-5 also denied witnessing staff handle resident in a rough manner or causing injuries to residents in care. Third allegation: Staff left resident with soiled bedding. Regarding the allegation “Staff left resident with soiled bedding” Based on observation and the review if R#2 photo LPA could not determine if R#2 bedding was soiled. Based on image LPA could not determine if R#2 bedding was soiled as the image did not display R#2 bedding to appear wet. LPA conducted interviews with R#3-6 LPA went over the alleged allegation with R#3-6 and all denied being left on soiled bedding. LPA conducted interviews with S#2-5 LPA went over the alleged allegation with staff and all denied leaving residents bedding wet or soiled. S#2-5 informed LPA that the facility provides housekeeping who changes residents sheets and conducts laundry service once a week and or as needed. Based on corroborating evidence the department has determined that the above allegations are Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Ashely Willett.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 56-AS-20230428113629

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(2) · Plan of correction due date: Dec 10, 2025

Incidental Medical and Dental Care 87465 (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidence by: Based on observation, interviews and record review the licensee did not provide medical assistance on a timely manner for R#1 which poses an immediate Health, Safety, or Personal Rights risk for persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Licensee has agreed to read of the entire "Incidental Medical and Dental Care" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign in sheet signed by all care staff by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1)(2) · Plan of correction due date: Dec 26, 2025

Personal Rights of Residents in All Facilities 87468.1...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons...(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on observation, interviews and record review the licensee did not follow Personal Rights Regulation for R#2 which poses an immediate Health, Safety, or Personal Rights risk for persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Licensee has agreed to read of the entire "Personal Rights of Residents in All Facilities" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign-in sheet signed by all care staff by POC date 12/26/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(3) · Plan of correction due date: Dec 26, 2025

Personal Rights of Residents in All Facilities 87468.1...(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. Based on observation, interviews and record review the licensee did not follow Personal Rights Regulation for R#2 which poses an immediate Health, Safety, or Personal Rights risk for persons in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Licensee has agreed to read of the entire "Personal Rights of Residents in All Facilities" regulation and provide training to all care staff pertaining to the regulation stated above. The licensee will email LPA a statement of understading and will provide a copy of the training sign-in sheet signed by all care staff by POC date 12/26/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Cynthia Figueroa and was granted entry to the facility. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (117) current census (100). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med-Room office inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Cynthia Figueroa.the state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a case management visit regarding an incident that occurred with resident #1 (R1) at the facility. LPA Prieto met with Business Office Director Diaz and explained the element of the visit. LPA Prieto interviewed R1, who stated that the memory of the incident was not certain, but once repeated to from the written incident report the incident of walking out to the facility courtyard sounded familiar and something the R1 would do to get fresh air. Facility staff followed the proper protocol of notifying medical response team, responsible parties and Licensing staff. LPA Prieto obtained pertinent documentation related to this incident. No deficiencies were cited during this visit. This report was signed by LPA Prieto and MS Diaz and a copy was left at the facility.the state’s words, verbatim · CDSS document, Apr 2, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced annual required visit. LPA was greeted and granted entry to the facility by Executive Director Figueroa. LPA explained the nature of today's visit. . LPA accompanied with MS Figueroa, conducted a general overall inspection, which included, but was not limited to the following: Physical Plant: The facility was not operating over capacity or beyond any conditions and limitations on the license. Facility is being maintained at a comfortable temperature for residents. All outdoor and indoor passageways are kept free of obstruction. Hot water temperature was measured at resident bathrooms are within regulation. There are grab bars for each toilet, bathtub and shower used by residents. Smoke detectors and carbon monoxide devices were tested by the Fire Department and found to be in working order. Inspection document was obtained. Facility sprinkler and kitchen sprinkler / extinguisher systems were tested and found to be in working order. Food Service: There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods. Kitchen is well staff and aware of resident's specific dietary needs. Kitchen area is clean and sanitary. Care and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. The facility is appropriately staff during night shift hours. Record Review: LPA requested and reviewed (10) resident and (5) staff files. LPA reviewed staff files for current CPR/1st aide certificates, TB results, and required training's. LPA reviewed client files for admissions agreement, physician report, and needs and service. Administration: The last disaster drill was conducted on 2/15/2024. LPA did not observe any excluded individuals on the premises at time of visit. The Administrator appears to be on the premises a sufficient number of hours to manage and oversee the business operation. Medical Related Services: Prescriptions and non-prescription PRN medications contain a signed and dated written order from a physician. Medications are centrally locked in the staff office and inaccessible to residents in care. Medications are being administered as prescribed by physician's directions. No deficiencies cited. An exit interview was conducted where this report was provided and discussed with MS Figueroa.the state’s words, verbatim · CDSS document, Feb 22, 2024

Allegation investigated: Resident eloped from facility without staff knowledge sustaining an injury.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Cadence at Rancho Cucamonga unannounced to initiate a complaint investigation into the allegation listed above. LPA entered the building, introduced self and stated the purpose of the visit. LPA was informed the Administrator is out for the week, the Memory Care Director was also out. LPA met with Vice President, Krystal Jenkins, who accompanied LPA to the Memory Care Unit. During today's visit, LPA walked through the facility memory care unit, interviewed staff and collected pertinent documentation. It is alleged that a resident eloped from the facility without staff knowledge sustaining an injury. During, staff interviews, LPA learned that on the evening of 1/15/23 R1 left the memory care unit through it's courtyard. R1 then walked to the Del Taco on the corner of the nearest intersection. When staff was made aware R1 had left the facility, staff attempted to pick her up, but R1 suffered an injury on her knee and was taken to the hospital. Since the elopement, the facility has increased R1's supervision and added new door alarms to the courtyard entrances. The resident's family contracted home health services for one on one supervision. **Please see LIC9099-C Substantiated R1's family has also agreed to increase the number of visits and outings with the resident. The incident was communicated to R1's Physician, who is making adjustments to R1's medications to aid in the prevention of wandering. A record review of R1's file revealed that the resident is unable to leave the facility without supervision. Also, R1 has a history of wandering. LPA also reviewed the facility's staff schedule and found that the facility is adequately staffed for the number of residents in care. After the incident occurred, the facility provided staff an in-service training in elopement which reviewed facility protocol for resident elopement. Based on LPA's observations, record reviews and staff interviews, we have substantiated the complaint allegation(s) as valid and that a violation has occurred based on the preponderance of available evidence. A deficiency will be cited to address the above mentioned concerns. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative.the state’s words, verbatim · CDSS document, Jan 22, 2024 · control 56-AS-20240117121131

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80078)a) · Plan of correction due date: Jan 22, 2024

80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by: Based on record reviews and staff interviews, staff did not provide adequate care and supervision for R1 on 1/15/24, when the resident left the facility on foot without supervision or knowledge R1 had eloped. The poses an immediate Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: A plan of correction was already implemented - The facility increased supervision, R1's family hired a home health agency to provide additional supervision. R1's family also agreed to increasing the number of viisit and outings. R1's physician was notified and will adjust medications Additionally, the facility has installed additonal door alarms/ motion censors. Lastly, the facility has provided an In-service (additional training) with elopement and procedures.