complaint·October 18, 2025

The investigation revealed the following: Allegation - Lack of supervision resulted in the resident eloping from the facility. It was alleged that Resident #1 (R1) had 6 elopements in 2022 while residing at the facility. Based on information gathered, R1 had eloped from the facility at least twice on different occasions. Therefore, this allegation is deemed substantiated. LPA Stephanie Torres interviewed four (4) staff in 2022, and all stated that R1 had eloped at least once from the facility. In addition, LPA Torres interviewed R1 who provided the details on how the resident eloped on one of the occasions from the facility. LPA Cynthia Chan obtained and reviewed documents on R1. R1 was admitted to the facility on 8/19/22. The physician’s report stated that R1 is unable to leave the facility unassisted. The facility provided an incident report for R1’s elopement on 10/16/22, which noted that R1 eloped from the west side door of the memory care unit. LPA interviewed three (3) staff during the visit today. Staff stated that some residents will attempt to exit through the delayed egress doors, but when staff hear the alarm, they will quickly get to the exit and redirect the residents away from the door. Staff stated they are always supervising residents to ensure their safety. The three (3) residents interviewed today stated the staff are always present and assisting them with their needs. One of the resident stated that when the exit door alarms go off, the staff will rush to the door and bring back the resident. Based on LPAs interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Correction was reviewed and developed with the Executive Director, Jimmy Stewart, via telephone. A copy of this report and appeal rights were provided.