Incident investigation·August 6, 2025

On 08/06/2025 at 9:25 AM, Licensing Program Analysts (LPAs) David Doidge and L. Alexander arrived unannounced to conduct case management inspection regarding an elopement from an Unusual Incident Report dated 08/04/2025. LPAs met with Victoria Puruganan, Licensee/Administrator and explained the purpose of the visit. LPAs obtained a copy of R1’s Physician’s report (602) and Appraisal Needs and Services Plan (ANS). LPAs interviewed Administrator about incident. Around 1PM, R1 was seen walking out the front door by S2. Previous Physician’s Report shows resident able to leave unassisted. Administrator said that R1 would walk to the local store on own, and per previous 602, R1 was able to do that. Upon learning of elopement staff walked the block to look for resident. Most recent 602, dated 05/02/2025 confirms resident is unable to leave the facility unassisted. A new Appraisal Needs and Services Plan was not created, and staff were going off of previous information. An immediate and repeat civil penalty of $1000 is hereby assessed. Exit interview was conducted with Licensee/Administrator, Victoria Puruganan, copy of this report and Appeal Rights provided.