Complaint·February 12, 2026

INVESTIGATION REVEALED THE FOLLOWING: Allegation #2: Staff did not adequately supervise resident in care resulting in resident sustaining injuries. It is alleged that Resident #1 (R1) sustained injuries due to inadequate supervision by staff. On January 18, 2026, (R1) reportedly eloped from the facility without staff supervision and sustained injuries. Upon (R1's) return to the facility, nursing staff evaluated (R1) and observed skinned knees, swollen palms, and bruising. This indicates that (R1) wandered out into the community unsupervised and likely fell at some point during the elopement. No further details regarding this incident were provided. On January 26, 2026, and February 12, 2026, between 11:50 AM and 01:00 PM, the Department interviewed with staff members identified as Staff #1 through Staff #6 (S1-S6). Five (5) out of the six (6) staff members were able to validate this claim that (R1) sustained injuries during an elopement from the facility. During the interview, staff members (S1-S5) confirmed that on Sunday, January 18, 2026, at approximately 12:36 PM, Resident #1 (R1) left the facility unaccompanied. Upon returning, (R1) sustained injuries to the knee and palm. Photography of the injuries was shown and confirmed that they occurred during the elopement and not before according to (S1-S5). Based on information from (S1-S5), it was determined that individual (R1) received first-aid care following the fall. (R1) did not require hospitalization and did not sustained any fractures as a result of the incident. On January 26, 2026, between 11:00 AM and 11:23 AM, the Department interviewed a resident identified as Resident #1 (R1). During the interview, R1 recalled leaving the facility alone but could not remember what happened afterward. The Department reviewed video footage from that day, which shows (R1), who resides in room #345 on the third floor, taking the elevator down to the garage's basement level. (R1) exited through the fire exit door unassisted by staff, and walked out onto Hayworth Avenue. Further review of the Unusual Incident/Injury Report LIC 624 (dated 01/24/26) verified (R1's) unassisted elopement with injuries. Further review of (R1's) Physician's Report for Residential Care Facilities for the Elderly LIC 602A (dated 09/11/25) (R1) has been assessed, and it is noted that allowing to leave the community unsupervised may present risks related to (R1's) health and mental well-being. (Evaluation Report continues LIC 9099-C) 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. *Immediate Civil Penalty issued* ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).