Incident investigation·May 7, 2026

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced Case Management – Incident visit to the facility. A case management report is being issued today in conjunction with complaint control number 31-AS-20260506151957; however, the incident reviewed during today’s visit is not related to the complaint allegations. On 05/01/2026, Community Care Licensing Division (CCLD), Regional Office (RO), received an incident report regarding a missing resident incident involving Resident #1 (R1) that occurred on 04/23/2026 at approximately 11:45 AM. According to the report, the Med-Tech on duty notified facility staff that R1 was missing and could not be located within the community. Facility staff conducted a search of R1’s room, surrounding vacant rooms, and interior areas of the facility; however, R1 could not be located. Staff members were alerted, and a community-wide search was initiated. The Wellness Director searched the surrounding exterior areas while the Maintenance Director drove throughout the nearby community in an attempt to locate R1. The assigned caregiver reported escorting R1 to the dining room for breakfast and assisting R1 back to the room at approximately 9:00 AM. R1’s roommate reported seeing R1 prior to breakfast but did not observe R1 afterward. While the Wellness Director was preparing to contact the Los Angeles Police Department (LAPD) to report R1 missing, the facility received a telephone call from LAPD informing the facility that R1 had been located with no apparent injuries. However, the facility transferred R1 to a local hospital for further evaluation. Continue on LIC 809C During today’s visit, LPA reviewed R1’s Physician’s Report dated 04/16/2026 and R1’s Appraisal Needs and Services Plan. LPA observed that R1 has a diagnosis of dementia and that the Physician’s Report specifically documents that R1 is unable to leave the community unsupervised. LPA conducted an interview with the Administrator, who stated they did not know how R1 exited the facility, despite the facility having an egress door system in place. Based on records reviewed and statements obtained, the facility failed to provide adequate supervision to R1, resulting in R1 leaving the facility without staff knowledge or assistance despite documented supervision needs and diagnosis of dementia. The facility’s failure to adequately supervise R1 placed R1 at risk of harm. A deficiency issued and appeal rights explained. Exit interview conducted and copy this report signed and delivered.