Incident investigation·March 30, 2026

On March 30, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on an incident that occurred on 3/15/26. LPA met with Administrator, Ping Jing Zhao and explained the purpose of the visit. The Licensee reported, on 3/15/26 at approximately 11:40am, staff went to Resident 1's (R1's) room to assist him/her with lunch, however discovered that R1 was not in his/her room. Staff searched the facility but was unable to locate R1. Administrator was notified and police was contacted to report R1 missing. Staff searched the neighborhood while waiting for the police's assistance. Police called shortly after and informed facility that the emergency department reported a patient matching R1's description. According to the hospital, a passerby saw R1 kneeling on the sidewalk and called emergency medical services. R1 was evaluated at the hospital and discharged back to the community. During the visit, LPA interviewed administrator, toured the facility, and reviewed R1's file. According to R1's file reviewed, R1 has a diagnosis of dementia and is unable to leave the facility unassisted. R1's physician's report dated 4/17/25, notes that R1 does get confused/disoriented and does have a wandering behavior. According to the administrator, this is the first time R1 has eloped from the facility and neither administrator nor staff were aware that R1's physician documented R1 as having wandering behaviors. According to staff interviewed and observations, the door alarms were not working. According to staff, the receiver for the door alarms was not plugged in and has not been plugged in for a while. (continue to 809C) After the incident occurred, administrator reached out to the physician who provided facility with an updated physician's report for R1. According to R1's physician's report dated 3/21/26, it indicates R1 is now allowed to leave the facility unassisted and has occasional confusion. Nevertheless, due to the alarms not turned on and not operating, R1 who has a diagnosis of dementia, has wandering behaviors and is unable to leave the facility unassisted was able to leave the facility without supervision and was found at the hospital with minor abrasions to the knee. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Copy of appeals rights is provided. This report is reviewed and discussed with the Administrator; a copy is provided.