complaint·December 18, 2025

[Continued from LIC 9099] On 12/17/25, the Department received an incident report from the facility regarding the elopement of R1. Per the report, the facility had received a phone call from the fire department that the resident was at their fire station. The fire department transported R1 to the hospital for evaluation and was discharged back to the facility same day with no noted injuries. Per interview with administrative staff, after review of facility camera footage, it was determined that R1 had wandered alone from their unit to the ground floor common area and eloped through a side door by the cafe into the fenced in patio area outside. R1 then exited through the gate leading from the patio to the front entrance and street where staff did not notice R1 wander away. Per administrative staff interview, the external doors and gate were not alarmed during the day. Per review of R1's records, R1 is diagnosed with Dementia and is unable to leave the facility unassisted. Per R1's assessment and service plan dated November 2025, R1 required escorts while going to meals and activities due to confusion. Additionally, the service plan stated that R1 required redirection and guidance, which is noted to be done through the use of frequent "eyes-on" checks. R1 is also noted to have a score of two (2) on their wander risk, and a comment that R1 "likes to walk outside in the neighborhood at home." Interview with R1's spouse revealed that R1 had attempted to wander off the facility once before but that staff immediately saw and redirected them back into the property. Based on LPA's review of records, interviews with staff, residents, and outside sources, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22, Division 6 on the attached 9099D. As this is a violation pertaining to absence of supervision, a Zero Tolerance Violation (ZTV) Civil Penalty is being assessed. The Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. An exit interview was conducted with Executive Director Arp to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.