Incident investigation·October 31, 2025

Licensing Program Analyst (LPA) Perchui Milena Khurshudyan, conducted unannounced Case Management visit - Incident to this facility and met with Peter Bonilla - Executive Director (ED) and Liliana Solorzano - Resident Care Director (RCD). LPA disclosed the reason for the visit. Today’s case management visit is to follow up on special incident report (SIR) reported to Community Care Licensing (CCL) on 10/25/2025 and to obtain additional information regarding the incident. On October 25, 2025, Community Care Licensing (CCL) received a Special Incident Report (SIR) from Memory Care Program Director – Diane Parras, reporting that Resident #1 (R1) residing in room # 223 in Memory Care Unit, attempted to escape from the facility. Interview with the ED and RCD revealed that R1 transferred to Memory Care unit two (2) days prior to the incident and did not show any signs of aggression or unusual behavior. Interview with R1’s roommate Resident #2 (R2) revealed that the day of the incident R1 was standing up at the sliding door starring outside and was walking inside the room not allowing R2 to sleep. R2 heard the sliding door open, however, fell asleep and couldn’t recall anything else after that. Additionally, interviews with staff revealed that approximately 2:20 am Staff 1 (S1) conducted routine checkup to R1s room and observed that R1 was still awake. Interviews also revealed that S1 came back again at around 2:35am and discovered that R1 managed to take off the installed hatch lock from the sliding door and had bed sheets tied on the balcony and climbed down to first floor landing in room # 121 balcony. 911 was immediately initiated and R1 got transferred to Northridge Hospital where R1 got evaluated and no fractures and / or injuries were found. After evaluation, R1 transferred to Kaiser Woodland Hills for further care and was admitted with diagnosis of paranoia. Continue on LIC809-C LPA conducted physical plant tour, checked six (6) random residents’ rooms and observed all residents’ rooms have balconies and sliding doors. Additionally, LPA observed and confirmed that all rooms have hatch locked installed on each sliding door which does not allow the doors to open beyond six (6) inches. After the incident, the management installed additional hatch locks and security alarm signals on the upper part of all sliding doors to protect residents’ safety and prevent incidents in the future. Lastly, during today’s visit, LPA requested the maintenance staff to remove one of the hatches and observed that it is not possible even for maintenance staff to remove the hatch lock without proper tools. The removal process took about 5 minutes. The facility followed all the appropriate protocols to prevent R1's elopement; and therefore, no deficiencies will be issued during today’s visit. Exit interview conducted, copy of the report delivered.