Incident investigation·May 28, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason for the inspection was to follow up on an incident report recently submitted to the Department involving resident (R1) who eloped from the community on May 26, 2026 (10:53 am). The RCC explained that (R1) was able to exit the facility through the front entrance without being observed by staff because the concierge staff had to cover for a care staff who had called out for work around 7:20 am after the morning shift began. At the time (R1) exited the building, the concierge staff was attending to residents at the other end of Hall #1, which is away from the front entrance. The RCC added that (R1) began pushing on the front door and then walked away from the door when the alarm was triggered; however, when the alarm stopped, (R1) walked back to the front entrance, exiting to the parking lot. The RCC stated she and staff immediately searched within the facility but were unable to locate (R1), who wasn't able to be seen on the cameras. At 11:00 am, the RCC and a Med-Tech drove in separate cars to search for (R1) in the nearby area, but were not able to locate them. Around 11:15 am, the local police were contacted and at 12:14 pm, (R1) was returned to the community after being found in a nearby neighborhood. The incident report notes (R1) returned without any "injuries, pain, distress or change in condition." The RCC stated that following the incident, maintenance staff checked the front door to ensure the door doesn't unlock before 15-20 seconds of the alarm sounding. The RCC indicated that staff will be instructed today (3:15 pm) on how the timing works on the egress door unlocking after the alarm sounds. *cont on 812C-1.. 809C-1.. The RCC stated that a Wander Guard anklet was previously placed on (R1); however, (R1) would regularly tear it off, and staff would find it in (R1's) room in the trash can. Before (R1) exited from the community, staff ensured that (R1) was wearing the anklet earlier that morning, but it was found in the trash can when searching for (R1). LPA and RCC spoke with (R1) during today's inspection in their room. LPA observed (R1) to be wearing a necklace with a monitoring device. (R1) admitted to throwing away anklets that were previously placed on them. LPA stated to (R1) that for their safety, they need to have a buddy with them when leaving the facility. (R1) appeared to understand. The RCC stated that (R1) left the facility due to wanting to walk, and staff will continue to take (R1) on walks. The incident report notes that updates were made to (R1's) Elopement Risk Evaluation, Assessment and Service Plan following the incident. Additionally, the report notes staff will be retrained on elopement response as well as door safety and monitoring procedures. Additionally, the RCC stated (R1's) primary care physician is looking into possibly modifying medications (R1) is currently taking. The RCC stated she will look into offering a different kind of monitoring device, if needed, that is compatible with the current Wander Guard system. Per California Code of Regulations, Title 22, Division 8, Chapter 6, the following (1) deficiency is being cited related to resident (R1), on the 809-D page. There is a civil penalty also being issued due to a repeat violation. Exit interview. Copy of report and appeal rights provided.