Complaint·May 29, 2026

Continued from LIC9099 S1 informed LPA that S1 was not in the facility at the time of the elopement and referred LPA to S2 for more information. S2 stated that S2’s had already gone home for the day when staff called to inform S2 of the elopement of R1. 911 was called before S2 returned to the facility, and S2 notified the responsible parties upon return to the facility. R1 had been given a tracking device by R1’s family members, as confirmed by R1’s responsible party, and the family used the device to locate R1 and direct the police to R1’s location. R1 was returned to the facility and evaluated by staff and later a physician with no health or physical issues. S2 informed LPA that a staff member was in the memory care unit delivering food and held the door open for R1 thinking that R1 was not a memory care resident. R1 proceeded down the elevator and walked out the front door. S2 reviewed security cameras and saw that at the time of R1 elopement, a group of visitors had all walked out together, making it difficult for the concierge to see R1. S2 informed LPA that food prep staff had been given key fobs to access the memory care unit to ease the delivering of meals. The food staff member was not familiar with any of the memory care residents and simply mistook the resident for a visitor. Based on interviews conducted the above allegation is SUBSTANTIATED. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED . Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty. Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy Exit interview conducted, Appeal Rights, and a copy this report provided.