Complaint·January 26, 2026

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff did not adequately supervise resident in care resulting in resident eloping from the facility. It is alleged that the facility staff failed to adequately supervise Resident #1 (R1), resulting in (R1) leaving the facility without permission. Reports indicate that (R1) exited the facility unattended around 12:30 PM on Sunday, January 18, 2026. No further details regarding this incident were provided. On January 26, 2026, between 11:50 AM and 12:00 PM, the Department interviewed with a staff member referred to as Staff #1 (S1). During the interview, (S1) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied. Video footage from that day shows (R1), who resides in room #345 on the third floor, taking the elevator down to the basement level of the garage. (R1) exited through the fire exit door, which was supposed to remain unlocked under City Fire Department regulations, and walked out onto Hayworth Avenue. (S1) explained that the video showed a visitor pressing the elevator call button in the garage while (R1) was inside the elevator. When the elevator doors opened for the visitor, (R1) exited the elevator and left the facility through the fire door. (S1) indicated that, at the time of the incident, the facility had three care staff members working on the third floor and front desk staff monitoring the surveillance security displays. Despite this, (R1) still managed to leave the facility. On January 26, 2026, between 11:00 AM and 11:23 PM, the Department interviewed a resident identified as Resident #1 (R1). During the interview, (R1) recalled leaving the facility unaccompanied but could not recall the exact date and time of the incident. (R1) demonstrated step by step how to call the elevator. (R1) pressed the elevator call button on the third floor and walked in, then pushed the close button. When the elevator doors closed, (R1) waited for the elevator to move, but movement would not occur without entering a code or selecting another floor. (R1) did not proceed to activate any buttons. The elevator was then summoned to the basement garage, and (R1) also showed how to exit the facility through the fire exit door. The Department reviewed the video footage of the incident that occurred on January 18, 2026. The review confirmed the information provided by (S1) that the visitor summoned the elevator at the garage level, which then summoned the elevator car. (Evaluation Report continues LIC 9099-C) The footage showed that (R1) exited the elevator and appeared to wander out, looking apprehensive and disoriented. Further analysis of the Unusual Incident Report LIC 624 (dated January 24, 2026) and the Physician's Report LIC 602A (dated September 11, 2025) revealed that (R1) exhibited unsafe wandering behavior and signs of sundowning. Preplacement assessment Information LIC 603 (dated September 10, 2025) (R1) requires special observation/night supervision due to confusion, forgetfulness, and wandering. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency were observed, and citation issued (ref. LIC 9099 D). An exit interview was conducted with Stephanie Brynjolfson, and copies of the report and appeal rights were provided.