Incident investigation·April 1, 2026

On 4/1/2026 LPA Grace Donato made an unannounced Case Management-Incident visit. LPA met with Staff Lea Pantangco. LPA explained the purpose of the visit. CCLD received an incident report regarding a resident (R1) who eloped from the facility on 3/27/2026. R1 asked another resident (R2), to open the door out of the house. While caregiver S1, was getting groceries on the lower level, R2 was trying to be helpful and let R1 outside. Based on records review R1 has neuro cognitive issues and may not able to leave the facility unassisted. LPA interviewed ADM through the phone and it was mentioned that a staff left the residents on the 2nd floor to get some groceries downstairs. R2 opened the door for R1 and R1 was able to go out. LPA observed all doors have alarms that has keys to be able to turn it off. The main door on the 2nd floor where R1 went out has the keys kept in the drawer by the door, easily accessible by other residents. R1 has returned back to the facility after a few hours. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Report is reviewed with the assistant administrator and a copy is provided with appeal rights.