complaint·October 15, 2025

During today’s visit, the LPA and the LVN conducted a brief safety check tour at 1:33PM, and no immediate concerns were observed. The following was then determined: Allegation: “Resident wandered away from the facility due to lack of care and supervision from staff.” It was reported that on 08/01/2025, Resident #1 (R1) wandered away from their Assisted Living Facility and was discovered by a bystander who contacted the Los Angeles Police Department (LAPD). Los Angeles Fire Department (LAFD) arrived on scene at 8:16PM and transported R1 to St Joseph’s Hospital for further evaluation. Interviews with eight (8) out of ten (10) staff revealed that the facility’s protocol for a missing resident or elopement includes immediate notification of all Supervisors and the Med-Tech in charge. Staff are expected to conduct a room-to-room and facility grounds search. If the resident cannot be located, the Supervisors and Med-Tech are responsible for notifying law enforcement and the resident’s family. The reception desk is equipped with an “elopement book,” which contained photos and names of residents who are not permitted to leave the facility unassisted, per their Physician’s Report. Staff reported that identifying which residents can and cannot leave the facility unassisted was “general knowledge.” Staff #1 (S1) stated they were unable to identify which residents had clearance to exit the facility unassisted and had initiated the inquiry independently. S1 also expressed the belief that other staff were similarly uninformed unless they sought out the information. Staff #2 (S2) reported that an Agency staff worked the evening reception shift on 08/01/2025 and had previously assisted the facility in the past. The facility’s perimeter is secured against outside access; however, individuals inside the facility can exit freely. When a perimeter door is opened, reception staff are alerted through an auditory alarm, a visual blinking light, and TV monitors that focus on the open door. Continued on LIC 9099-C Interview with staff and record review confirmed that R1 was not authorized to leave the facility unassisted. R1 was known to wander within the facility, including occasional visits to the rear parking lot, but had no prior history of elopement. R1’s Physician’s Report noted that R1 was at times confused/disoriented, had wandering behavior, occasional sundowning behavior, and recent hospital documentation indicated that R1 was diagnosed with Alzheimer’s Disease. R1’s Appraisal specified that R1 experienced episodes of sundowning behavior which was manifested by wandering behavior. Those responsible for ensuring R1’s safety and understanding R1’s behavior included “nursing” and “all staff.” The facility’s camera footage captured the following on 08/01/2025: At 4:58:02PM, Agency staff and Staff #3 (S3) were present in the reception area. The Agency staff monitored facility cameras while S3 shredded documents. Nine (9) seconds later, R1 entered the camera frame and greeted both staff. At 4:58:23PM, R1 turned and walked away, making a lap around the first-floor hallways. R1 re-entered the lobby at 5:01:34PM. During this time, S3 was observed to be making copies at the printer, with their back facing the lobby, while the Agency staff was seated at the desk facing the lobby, turned to assist S3, also turning their back to the front door. At 5:01:45PM, R1 exited the facility through the front door with their walker. Visual and auditory alarms were triggered, and the TV monitors focused on the front door. At 5:01:50PM, S3 received a text message and proceeded to pull out their phone. The Agency staff returned to the desk at 5:01:51PM, disengaged the alarm, looked through the reception window at the front door, observed R1 walk away on the TV monitor, and then disengaged the TV monitor. During an interview with S3, they claimed they were not present during the elopement and had been notified of the incident by a coworker via telephone call. S3 did not provide further details. However, payroll records indicated that S3 worked from 6AM to 6PM on 08/01/2025. Staff #4 (S4) stated that they discovered R1 was missing at approximately 6PM and notified Staff #5 (S5), the Med Tech in charge of the evening shift. Continued on LIC 9099-C S5 also reported that they observed R1 was missing during the evening medication rounds and notified the Supervisors but did not notify law enforcement. S2 stated they received a call from facility staff at approximately 8:50PM regarding the missing resident and subsequently notified the Assistant Administrator and LVN. The three (3) Supervisors returned to the facility at approximately 9:15PM. Shortly thereafter, LAPD contacted the facility to report the missing resident. S3 returned to the facility during this time. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the allegation is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiency was cited (Refer to LIC 9099-D). Exit interview conducted. A copy of the Appeal Rights and report were reviewed and provided.