Incident investigation·July 1, 2025

On 7/1/25 at 3:15 PM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an elopement that occurred on 6/25/2025. LPA met with Executive Director Oreisha Morgan and explained the purpose of the visit. While at the facility on an unrelated incident LPA was made aware that R1 had eloped from the facility on 6/25/2025. Facility faxed incident report for elopement on 7/1/2025 at 5:56AM. R1 is a memory care resident. All egress doors were operational at the time of elopement and it is suspected that R1 exited memory care into assisted living when an unknown staff member departed memory care. R1 was observed in the parking lot by a S1 when arriving to work around 10:10PM. R1 was last observed in their room at approximately 9:40PM. R1 was found without injury and assessed. R1's care plan has since been updated and staff were provided an in service. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Facility did not prevent R1 from eloping Facility did not report incident in required 24 hour time frame The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.