- Date
- 6/15/2025
- Report number
- CALMS - 00083373
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide safe environment
- Result
- Substantiated
- Findings
- Based on observations, interview, and record review, conducted during a site visit on 06/25/25, the facility’s failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: At approximately 12:25 pm, the east gate was observed to be closed and locked on 06/25/25. The door alarm was working while the door was open. Signage was posted on the door to “ensure the gate is closed for our residents’ safety.” A review of Resident 1’s service plan updated on 04/02/25, progress notes dated 04/02/25 through 06/14/25, and incident report dated 06/15/25 indicated the following: Resident 1 was found outside the gates of the east courtyard on 06/15/25 near the dumpsters; Resident 1 was last seen five minutes prior to elopement and did not have any injuries or need medical care; and Resident 1 did not have a history of elopement or exit-seeking behaviors. In interviews with Staff 1 (Executive Director) and Staff 2 (Licensed Practical Nurse), they reported the gate hadn’t been closed correctly when someone had gone out earlier. The door alarm did not go off while the door was open, and staff had reported it had been turned off. The alarm was turned back on, maintenance was called, and the gate was checked and found to be in working order. Staff 1 stated they added another sign to make sure the gate was closed correctly. The facility’s failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated