Incident investigation·January 27, 2026

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to conduct a case management visit to follow up on an incident report regarding an elopement. LPA met with Administrator Jasmine Latu and stated the purpose of the visit. On January 5, 2026, the Department received an Incident Report (IR) from the facility. The incident report stated, on January 4, 2026 at 9:55am, a staff member witnessed R1 come down the elevator to the lobby alone. Staff member redirected R1 to the elevator to return R1 to the memory care unit on second floor. On January 5, 2026, LPA Manuel Monter interviewed ADM. ADM stated the elevator in the 2nd floor works once a staff member punches in a code, then they can go down. ADM stated that day, a staff member had punched in a code for a family to go down. ADM stated she was informed afterwards by that family that the resident joined them as they were going in the elevator. ADM stated the staff member who imputed the code should have waited for the door to close before leaving the area, to ensure no memory care resident sneaks in. On January 11, 2026, The Department received an Incident Report regarding R1. The IR stated on January 12, 202, at 5:13am, R1 had eloped from the memory care 2nd floor. Staff heard the alarms from the staircase alerting someone had opened the door at 5:11am. Staff went downstairs and found R1 had made it downstairs and was in the parking lot. R1 was redirected back to the memory care unit. Page 1 Out of 3. On January 12, 2026, the Department received an Incident Report regarding Resident R1. The IR stated on January 11, 2026, at Approximately 4:00pm R1 eloped from the facility. Facility staff searched for R1 when they could not find R1 to take him/her to dinner at 4:00pm. The IR states, “R1 was seen last at the start of PM shift at 3pm. Care staff let movers down at 4:00pm and R1 had got on the elevator and able to make his/her way out of the facility with them.” R1 was found by local Law enforcement at 4:30pm and was found on Meridian and Moorpark. R1 was returned to the facility safely at 4:40pm. On January 14, 2026, LPA Manuel Monter interviewed Staff S1-S5. 5 Out of 5 Staff interviewed stated only the staff know the code. 5 Out of 5 Staff stated once they put in the code, they open the door, which leads to the elevator. 5 Out of 5 Staff stated once the visitors/family is inside, the staff person will close the door and ensure no memory care resident sneaks in/ wanders into the elevator. On January 14, 2026, LPA Manuel Monter interviewed ADM. ADM stated R1 was able to elope because, on January 11, 2026, there was movers, moving in a new residents things to the memory care. R1 was able to go down the elevator with the movers. ADM stated the procedures for the elevator is as follows: the staff member unlocks the door by imputing the code. Staff is supposed to watch who enters the elevator then close the door. ADM stated there are residents who will try to sneak into the elevator as it goes down. On January 22, 2026, LPA Manuel Monter interviewed Former Wellness Director (WD) Ann Lee. WD stated he/she did complete the initial assessment for R1. WD stated the facility was aware of R1's wandering and exit seeking behaviors. WD stated R1 did had elopement attempts at his/her previous facility R1 resided in. On January 22, 2026, LPA Manuel Monter interviewed staff S6 and S7. S6 stated on the day of R1's elopement, he/she didn't know where R1 was because he/she was helping other residents. S6 stated he/she doesn't remember the last time he/she saw R1. S6 stated at 4:00pm, the staff didn't know where R1 was. S6 stated he/she doesn't recall if there was movers coming in and out of the memory care that day. Page 2 Out of 3. S7 stated the day of R1's elopement, he/she wasn't sure what happened. S7 stated the last time he/she saw R1 was when he/she assisted R1 to his/her room. S7 stated he/she then went to assist another resident. S7 stated there was a family moving a residents belongings into the memory care unit that day. S7 stated he/she was not by the elevator that day and doesn't remember opening the elevator door for them. S7 stated around 4:00pm, during dinner time, they could not find R1. S7 stated that was when they discovered that R1 was no in the memory care unit. The Department reviewed R1's Sonnet Hill Observations. Note dated January 11, 2026 states, R1 was adamant about leaving the facility, stood by the elevators, were able to redirect R1 to the community area multiple times. R1 did go to his/her room around 3:00pm. Staff realized R1 no longer in bedroom around 4:00pm and staff searched for R1. R1 came back at 4:30pm, escorted by local law enforcement. Note dated January 12, 2026, at 5:10am, a care giver heard a faint alarm and staff went to see if R1 was in his/her room. When staff checked R1 was not in his/her room. Staff went down the stairs and exited onto meridian and the resident was there at the light. R1 was escorted back to the building at 5:13am. The Department reviewed facility Meeting agenda dated January 8, 2026. Under agenda details, elopement, it states, "be aware of your surroundings in memory care residents could be lurking around the corner waiting to see if they can catch the elevator to leave." The Department reviewed R1's Physician's Report, dated May 14, 2025. The report states R1 cannot leave the facility unassisted and R1 has a neurocognitive disorder. An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 eloping from the facility. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Administrator Jasmine Latu and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3. END OF REPORT.