Incident investigation·October 28, 2025

Licensing Program Analysts (LPA)s Hanna Gough and Rose Ruppert made an unannounced Case Management visit to follow-up on an Unusual Incident Report received in the Regional Office. LPAs were greeted and granted entry by the Concierge at 8am. LPAs obtained the following documentation for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report, Resident Appraisal, Assessment, Service Plan Detail and Facility Progress Notes. LPA reviewed three of three staff files and obtained a copy of an employee Notice of Disciplinary Action. Per review of R1's Physician's Report dated 01/19/2022, R1 is diagnosed with Alzheimer's Disease. R1 is confused/ disoriented, has wandering behavior and is unable to leave the facility unassisted. The appraisal, dated 8/15/2024, states R1 wakes during the night searching for a family member. R1's Service Plan Detail, dated 2/11/2025 states R1 is exit seeking and a Care Conference was held with R1's Responsible Party on 2/14/2025 to discuss the updated care needs. LPAs reviewed the Unusual Incident Report submitted to the Regional Office by the facility for an incident that occurred on 9/25/2025 at 4:50am. R1 activated the delayed egress alarm and walked away from the stairwell. The night staff silenced the stairwell alarm but did not reactivate stairwell alarm. R1 engaged with staff in a hallway before entering the stairwell and exiting the facility to the sidewalk. Faciity staff initiated elopement procedures and were unable to locate R1 and contacted 9-1-1. During the call the dispatched Brea Police Department (PD) located R1 next door and returned R1 to the (Continued on LIC 809-C) (Continued from LIC 809) community and staff conducted a full body assessment and vitals were at baseline and no injuries were noted. Staff contacted Responsible Party (RP) regarding the elopement and a 1:1 personal companion was provided for R1 overnight. LPA also interviewed R1 on a health and safety check. Based on LPA's record review, observations and interview, the facility failed to secure exterior doors and alarms for dementia residents in care. A deficiency and immediate $500 civil penalty are being given per California Code of Regulations 87705(d). An exit interview was conducted with Tana McMillon, Regional Vice President of Operations, and copy of this report, LIC 809-D, LIC 421IM, LIC 811, LIC 859 and Appeal Rights were provided to the facility.