Incident investigation·April 30, 2026

On 4/30/2026, LPA Grace Donato conducted an unannounced Case Management - Incident visit. LPA met with Executive Director Tina Bagheri and explained the purpose of the visit. On 4/28/2026, CCLD received a report regarding a resident (R1) eloping from facility. R1 left facility around 6pm on 4/24/2026. R1 was located at a nearby business area at approximately 7:47pm. R1 was checked and was at baseline and no injury sustained. Based on interview with ED, the delayed egress sounded the alarm when R1 went out the door. The area where R1 went out has another exit door heading out on the street. There's also a stair case going down to the parking area. When the alarm sounded off staff went and checked and headed down the stair case to the parking area. Other staff members checked video surveillance and found out the R1 went to another exit door heading to the street. Facility did the protocol and searched for R1 involving police and available care staff. LPA observed 2 doors to exit from memory care area, both have alarms. After the incident, facility conducted an in-service training on 4/26 and 4/27 regarding Elopement Response Protocol to staff. No deficiency is cited today. Report is reviewed and copy is provided.