complaint·February 11, 2026

The Licensee reported a Licensing Program Analyst (LPA) was onsite for an annual inspection starting at 3:30 PM and it concluded at 6:00 PM. An interview with the LPA revealed they were onsite at the facility on July 31, 2024, from approximately 2:00 PM to about 6:00 PM. The LPA reported they were not aware a resident had eloped and staff did not disclose the incident during the inspection. Information obtained through a police report dated 07/31/2024, revealed that on July 31, 2024, at approximately 6:16 PM, law enforcement received a request to take a report for a missing person. Telephone contact was made with a facility representative at 6:27 PM and law enforcement arrived at the facility at 7:15PM. Law enforcement learned of R1’s location, which was the hospital, at 7:50 PM. Law enforcement then provided this information to the Licensee. The police report further revealed that a caregiver told law enforcement that R1 was last seen in the living room at approximately 3:30PM. The caregiver then went to start dinner and believed that R1 had gone to their room . The caregiver further reported to law enforcement that R1 had attempted to leave the facility on the same day at approximately 2:30PM. Staff brought R1 back inside of the facility and told R1 to stay inside. The report also revealed paramedics informed law enforcement that they had received a call for service regarding R1 being found laying underneath a car in the driveway and they transported R1 to the hospital. Medical records were obtained and reviewed. The record revealed that vitals were taken of R1 on 07/31/2024 at 3:36PM. This contradicts the staff who reported last seeing R1 at about 3:30PM in the living room. Further noted was that R1 presented at the emergency department after being found unconscious with their head under the bumper of a car. Skin temperature was noted at 107. Medical records show, in the emergency department, with cooling measures, rectal temperature on arrival was 103. R1’s diagnosis was noted as heat stroke, altered mental status and Acute Kidney Injury (AKI). Medical records revealed R1 was admitted to the hospital on 08/01/2024. Facility records were obtained and reviewed. R1’s Physician’s Report with a date of exam as 07/21/2024 revealed a primary diagnosis of Dementia. Under category of Mental Condition, the following was marked “yes”: Confused/Disoriented, Wandering Behavior and marked “no” for Able to Leave Facility Unassisted. The licensee was unable to provide a care plan because one had not yet been developed. R1 was admitted to the facility on 07/30/2024 and the licensee had planned to meet with R1’s family to develop the care plan on 07/31/2024, which was the day of the incident. A Pre Placement Appraisal was reviewed, dated 7/31/2024. Information reviewed does not have elopement concerns. According to Licensee, the Pre Appraisal was completed by responsible party for R1. An interview with a relevant witness reported notifying the Licensee, prior to R1’s admission, of R1’s wandering behaviors. This witness also reported speaking to a staff, but could not remember the name, who informed the witness that R1 had previously attempted to leave the facility on the same day, but was recovered by staff. This witness also reports facility staff admitted to disarming the alarm on the front door because it was annoying. The licensee denies the alarm was ever disarmed. Interviews with staff revealed, there were a lot of guests at the facility on the day R1 eloped and this could have led to staff not noticing R1 leave the facility. Based on interviews and record reviews, the allegation that resident wandered from the facility due to lack of staff supervision is substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. An immediate civil penalty of $500 is being assessed. The licensee was also informed that an additional civil penalty may be assessed in accordance with H&S Code Section 1569.49. An exit interview was conducted where a copy of this report was provided to Licensee Ma Satchel Lecita along with a copy of the LIC9099-C, LIC9099D, LIC 421IM and Appeal Rights were provided.