Complaint·March 2, 2026

and records reviewed revealed that when R1’s family member arrived at the facility at around 3:05 pm, R1 was not in their room; the staff began to search the property but R1 could not be found. R1’s family member contacted others at the family home approximately 1.6 miles away at which time it was discovered that R1 had arrived at the private residence on foot and alone. Interviews conducted revealed staff did not recall R1’s elopement however, record review revealed written documentation to verify staff was notified in writing of R1’s elopement. Interviews conducted revealed staff try to redirect residents who cannot leave unassisted; Residents’ pendants alert staff if they go off the property, and available caregivers will try to locate the resident. It is unclear if R1 was wearing their pendant or if the pendant alerted staff when R1 left the property. Record review revealed R1’s Physician’s Report (LIC 602) states R1 has a diagnosis of Aphasia and cannot leave the facility unassisted; and, R1’s Physician was informed of the elopement. Interviews conducted and records reviewed revealed staff could not determine how R1 eloped from the facility. Since the incident, Staff have implemented additional safety checks for R1. Based on records reviewed and interviews conducted, the allegation that Resident eloped from the facility due to lack of staff supervision is deemed Substantiated at this time. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.