complaint·February 18, 2026

Residents appraisal dated 10/26/2025 notes under Services needed, R1 needs special observation and night supervision due to confusion, forgetfulness & wandering. Record Review revealed Department received Unusual Incident Report from facility on 12/23/2025, notifying Department of R1’s exiting the facility without staff’s awareness. Incident report indicates that staff 1 & 2 were present in the facility and both helping assist another resident (R2) during the time incident occurred. Incident report stated that R1 had a history of sundowning and no previous incidents of exiting facility without supervision. Interviews with staff stated that staff searched facility and surrounding neighborhood for R1. Staff interviews stated that Licensee’s who were out of town during the time of incident and were contacted regarding R1. Staff Interviews stated that incident occurred around 4:30PM. Staff interviews revealed that Staff contacted family and local police regarding R1. Staff interviews also revealed that R1 had a 1:1 care plan for R1 between the hours of 5:00-10:00pm due to R1’s sundowning behavior. Five of Five staff stated R1 had no previous incidents of eloping from facility. Interviews with 3 of 5 staff state R1 was located by Police and taken to Local Hospital around 9:00PM. Interview with witness states R1 was missing approximately for four hours. Witness interview stated that Staff left R1 unsupervised knowing Their condition. Witness interview stated Facility had alarm for front door upon opening. During Department visit, LPA observed that each exits in and surrounding facility had audible alarms that chime each time someone exits the doors. Interview with staff 1 and staff 2 stated they did not hear alarm go off while they assisted R2 due to R2 was verbally loud during transfer to bed. LPA observed cameras in common areas and perimeter of home which Staff stated Licensee has access to. Per information gathered from Investigation, the preponderance of evidence has been met, deeming the allegation “Due to lack of care and supervision resulted in resident eloping” to be Substantiated. The facility is being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted with Representative and copy of report was discussed, provided along with appeal rights.