Complaint·April 6, 2026

The Department reviewed several documents, including the Facility Resident Roster (dated 01/22/26), the Personnel Report LIC 500 (dated 01/21/26), (R1's) Physician’s Report LIC 602A (dated 9/11/26), the Preplacement Appraisal Information LIC 603 (dated 09/10/25), Unusual Incident Report LIC 624 (dated 01/24/26), Facility Surveillance Camera Footage (dated 01/18/26), and other pertinent records associated with this complaint. Allegation #1: Staff did not adequately supervise resident in care resulting in resident eloping from the facility. Allegation #2: Staff did not adequately supervise resident in care resulting in resident sustaining injuries. It is alleged that the facility staff failed to adequately supervise Resident #1 (R1), resulting in (R1) leaving the facility without permission and resulting in (R1) sustaining injuries. Reports indicate that (R1) exited the facility unattended around 12:30 PM on Sunday, January 18, 2026. 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, 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 garage's basement level. (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. (Evaluation Report continues LIC 9099-C) Upon returning, (R1) sustained injuries to the knee and palm. Photography of the injuries was shown, and it was 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 sustain any fractures as a result of the incident. 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. However, (R1) recalled leaving the facility alone, but could not remember what happened afterward. (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. 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. An analysis of the Unusual Incident Report (LIC 624) (dated 01/24/26), the Physician's Report (LIC 602A) (dated 09/11/25), and Preplacement Appraisal Information (LIC 603) (dated 09/10/25) revealed that (R1) exhibited unsafe wandering behavior and signs of sundowning. This necessitated special observation and night supervision due to confusion and forgetfulness. The records also highlighted the risks of allowing (R1) to leave unsupervised, reinforcing the need for greater supervision. Video footage recorded (R1) shows taking the elevator to the basement and exiting unassisted onto Hayworth Avenue, leading to an unassisted elopement and subsequent injuries. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. (Evaluation Report continues LIC 9099-C) 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 was 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. INVESTIGATION REVEALED THE FOLLOWING: Allegation #3: Staff are not ensuring that resident's hygiene needs are being met while in care. Allegation #4: Staff are not ensuring that resident's clothing needs are being met while in care. Allegation #5: Staff are not ensuring that resident take their medications as required. It is alleged that the facility staff is not ensuring Resident #1's (R1's) hygiene, clothing, and medications are being met while in care. Reports indicated that (R1's) grooming and hygiene, noting that (R1) has been observed without socks, underwear, or bras. Additionally, reports stated that dental care has not been adequately addressed and that personal toothbrushes and toothpaste are unused. Further reports mentioned medication mismanagement and errors, mentioning that a resident had access to Miralax and prescription medications on January 13, 2026. No further details were provided regarding these allegations. On January 26, 2026, and February 12, 2026, between 11:50 AM and 03:45 PM, the Department interviewed staff member identified as Staff #1- Staff #6 (S1-S6). Six (6) out of the six (6) staff members are unable to support these claims. (S1-S6) reported that (R1) requires assistance with bathing, hygiene, grooming, and dressing. They noted that (R1) usually dress independently but occasionally choose not to wear undergarments or accessories. (S3-S6) mentioned that care staff attempt to help (R1) dress appropriately; however, (R1) often refuses their assistance and does not wear suitable clothing. Care staff must respect (R1) 's rights as a resident while also balancing the need to provide necessary care services. (S1-S6) disputed that daily hygiene care is not being provided to (R1). (R1) would conceal personal items, and that may include personal dental supplies provided by family representatives. But it does not verify that (R1's) dental hygiene care is not being met. The facility provides dental supplies (R1), which would take advantage of these complementary services. (S1-S6) reported they could not confirm that (R1) had access to Miralax and prescribed medications. According to (S1-S6), (R1's) management of medications has been consistently error-free. Medications are administered to (R1) exactly as prescribed by the physicians. On January 26, 2026 and February 12, 2026, between 10:50 AM and 12:14 PM, the Department interviewed resident members identified as Resident #1 through Resident #10 (R1-R10). Ten (10) out of the (10) could not corroborate these claims. (Evaluation Report continues LIC 9099-C) (R1-R10), reported no issues or concerns regarding staff assistance with daily hygiene, grooming, and clothing care. Furthermore, they expressed no concerns about the administration or management of their medications. All residents stated that they have not witnessed or experienced any issues of residents having access to medications. (R1-R10) acknowledged the commendable efforts of the staff, particularly regarding the care and supervision services provided. They noted the staff's responsiveness is to be recognized. On March 27, 2026, between 09:23 AM and 10:00 AM, the Department attempted to interview Witness #1 and Witness #2 (W1-W2), who are aware of these allegations; however, they were not available, and calls were not returned. The Department reviewed Resident #1's (R1's) Physician's Report for Residential Care Facilities for the Elderly LIC 602A (dated 09/11/25 & 09/25/25), Comprehensive Assessment/Observation (dated 09/10/25), Service Plan Detail (dated 01/22/26), and Preplacement Appraisal Information LIC 603 (dated 09/10/25) revealed (R1) requires partial assistance with hygiene, clothing, and dental care with care staff prompting assistance. Further review of Physician Order Review (dated 01/22/26) and Medication Administration Record (dated 01/01/26 through 01/31/26) revealed no errors, omissions, or discrepancies. An additional review of staff training records verified staff had completed Workplace Sensitivity Training Courses, including ADLs and Behaviors, Psychosocial Needs, Challenging Behaviors, Basic Essentials, Person Center Care and Medication Management. Based on the information gathered, there is not enough evidence to support the allegations mentioned above. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegations are determined Unsubstantiated . An exit interview was conducted with Stephanie Brynjolfson, and copies of the reports were provided.