Incident investigation·July 1, 2025

On July 1, 2025, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced case management visit. LPA met with Executive Director Stephanie Brynjolfson, and explained the purpose of the visit is in reference to an incident that occurred with Resident #1 (R1) on June 18, 2025. The Department received an Unusual Incident Report LIC 624 on June 25, 2025, regarding an incident that occurred at 7:45 PM. It was reported that Resident #1 (R1) was able to elope from the community unsupervised. (R1) had been admitted to the community on June 17, 2025, and was diagnosed with a Major Neurocognitive Disorder (NCD). (R1) resided on the third floor, known as "the Loft." According to Staff #1 (S1), (R1) had one-on-one private care staff who had taken a break. During this time, S1 informed the Silverado care staff assisting another resident. In a matter of seconds, while the care staff were distracted, (R1) left without supervision. (R1) managed to operate the elevator and descend to the first-floor lobby, passing the front desk receptionist without being recognized, and exited through the front doors. (R1) was found unattended on Fairfax Avenue. (S1) stated that once returned to the community, (R1) had a whole body and skin assessment, saw no signs of injuries or discomfort. (S1) notified the family representative and medical physician of the incident. The Department reviewed (R1)'s Medical Assessment (dated April 17, 2025) and Physician's Order Review. It revealed that (R1) has a history of disorientation and sundowning behavior, which can be associated with wandering and eloping behaviors in residents diagnosed with (NCD). The licensee violates Title 22, Section 87411, Personnel Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted, and a copy of the Evaluation Report and Appeal Rights was provided to Stephanie Brynjolfson.