On 11/14/2024, the Department conducted a follow-up visit to investigate the circumstances and collect records related to the incident. At that time, the Department determined that further investigation was warranted.

A review of facility records was conducted. R1’s Physician’s Report revealed a diagnosis of dementia and documented that they were unable to leave the facility unassisted. An addendum to the Physician’s Report, completed on 12/21/2023, stated, “Patient to leave facility with family only.” R1’s updated Physician’s Report, dated 10/22/2024, documents, “At risk if allowed to leave the community unsupervised due to dementia or cognitive decline.” (CONTINUED ON NEXT PAGE, LIC 809C)

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

On 11/22/2024, a Department Investigator returned to the facility to conduct an additional investigation. An interview was conducted with the Executive Director who believed that R1 was never an elopement risk. ED knew R1 was diagnosed with Dementia, but their family wanted them to live in assisted living, and there was a note from R1’s doctor explaining that R1 can walk the premises of Paradise Village with their walker. The note was shown to the investigator which read that R1 “may have access to walking within the premises of Paradise Village with [their] walker.”

The ED explained they had heard that R1 had wanted to vote the day of the incident and believed that was probably what caused them to leave.

Interviews were conducted with staff who were present on the evening of the incident. Staff reported that R1 was seen inside the facility at 4:30 p.m., 5:00 p.m., 6:00 p.m., and 6:30 p.m. S2 reported that their shift ended at 7:00 p.m. but that they had left the front desk to clock out and could not recall whether another staff member was present at the desk at that time.

Video surveillance was reviewed in the presence of ED, which showed that at approximately 7:00 p.m. on 11/5/2024, R1 left the community grounds unaccompanied, using their front-wheeled walker, heading eastbound on E. 4th Street. The Plant Operations Director (OD) was also interviewed and noted that they were responsible for surveillance for the entire compound, including the licensed facility and additional buildings not licensed by the Department. All surveillance footage specific to the licensed facility for the date and time of the incident was requested, and OD stated they would provide copies via email.

A review of Law Enforcement records indicated that the National City Police Department received a call for service at 9:52 p.m. reporting that, approximately half a mile away from the facility, a woman (later identified as R1) had been “stuck in a ditch” for several hours. R1 was transported to the hospital, and the facility was notified that R1 was found approximately three blocks away.

On 1/8/2025, the Department interviewed R1’s physician (OS1) and questioned them regarding the note written for R1. OS1 reported that the note was written to allow R1 to walk within a “locked community,” and that they did not recall ever providing notes permitting R1 to walk without supervision. (CONTINUED ON NEXT PAGE)

On 1/27/2025, R1’s assigned caregiver (S3) was interviewed again regarding the incident. During the conversation S3 noted that about a week prior to the incident, R1 said that they were ready to move to memory care, and that this was reported to the facility med-tech (S5).

S5 was interviewed on the same date and corroborated that R1 had a history of falls, and was reporting they were ready for memory care prior to the incident, which had been communicated to the Health Services Director (HSD). HSD was contacted on 1/29/2025 and denied any awareness that R1 had said she was ready to move to memory care.

Based on interviews conducted and a review of pertinent records, R1 left the facility without required supervision on 11/05/2024 undetected by staff due to a lack of supervision, resulting in serious injury.

A deficiency was cited and immediate civil penalty assessed [see attached LIC 809(D) and LIC 421M]. The Licensee was further advised that additional civil penalties are under review by the Department’s legal division and may be assessed at a later date.

An exit interview was conducted with the Sr. Executive Director Bill Lawson, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).