Incident investigation·October 2, 2025

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – incident visit. The purpose of this visit it deliver the final report on a case management that was initiated on 08/25/2025 regarding an elopement that occurred on 08/20/2025. LPA met with Administrator, Lisa Lanford. On 08/21/2025, the Department received a verbal report regarding resident (R1) who eloped from the facility on 08/20/2025. It was reported that R1 was found by a neighbor around the corner of the facility (about 450-500 feet away) around 2:00PM. The neighbor called 911 and when 911 arrived, R1 was observed disoriented and was taken to the hospital where it was found that R1 was diagnosed with an infection. It was stated that R1 did not sustain any injuries during the elopement. Based on interview with staff (S1), around 4:15PM it was reported by another staff (S2) that R1 was missing when they were gathering all the residents for dinner time. Staff immediately went to look for R1 in all the rooms, interior and exterior of the facility but was unable to location him/her. Around 4:25PM, S1 called 911 and reported a missing resident. S1 states that while walking around the neighborhood, the police was driving by and informed S1 that R1 was found after 2:04PM and was found with no injuries. S1 states that R1 was sent to the hospital by the police due to confusion and unable to describe what happened. S1 stated that R1 returned to the facility on the same day. Page 1 of 2. S1 stated to believe that R1 exited through the main entrance which is unlocked and does not alarm during the day. S1 stated that this was the first time this happened with R1, as R1 does not have any history of elopement. S1 denied any other residents having a history of elopement. LPA observed that there are cameras throughout the common areas. S1 stated to have went through all the camera footage and did not find footage of R1 leaving the facility. Based on record review, R1 diagnosed with a neurocognitive disorder and is not able to leave the facility unassisted. After the incident, the Administrator updated R1's appraisal/needs and services plan to include the change of behaviors after the elopement. The Administrator also provided staff with an in-service training on topics of elopement and behavior management. Going forward, the Administrator will always have a staff standing in the common areas which is facing the main entrance to supervise the residents and main entrance. Administrator states the main entrance door will continue to be unlocked and not alarmed because they have many visitors throughout the day going in and out of the facility. The Administrator states future plans to install an electric gate that will require a code to enter. Based on the facility's compliance history, the facility does not have any reported history of resident's eloping. No deficiencies were cited per California Code of Regulations, Title 22. A technical violation was provided per Title 22 Section 87219(i). This report was reviewed with Administrator, Lisa Lanford and a copy of the report was provided. Page 2 of 2.