Incident investigation·July 3, 2025

On July 03, 2025, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Case Management – Incident visit regarding an incident that occurred on 06/20/2025 when the resident (R1) eloped from the facility. Upon arrival, LPA met with the Executive Director (ED), Stephanie Brice, and disclosed the purpose of the visit. LPA interviewed one (1) staff member: ED, and one (1) resident (R1). The ED stated that on 06/20/2025, at approximately 7 PM, S1 responded to the first-floor stairwell exit alarm. S1 did not see anyone around the exit, so S1 immediately called out on the walkie-talkie for the team to start apartment checks to ensure all residents were accounted for. At approximately 7:05 PM, S1 reported to the ED that R1 could not be located. Apartment checks continued, and other facility staff members began searching the outside areas and the immediate neighborhood. ED stated R1 lives on the fourth floor, and they are not sure if R1 took stairs from the fourth or any other floor. ED stated that at approximately 7:10 PM, the facility received a call from R1's former Physical Therapist (PT), who stated that R1 was with them and that they were bringing R1 back to the community. The ED contacted R1’s Responsible Party (RP) to inform them about the incident. R1 was brought back to the community. The PT informed the ED that they had seen R1 at the corner of El Camino and California Avenue. R1 stated that they had gone for a walk but forgot how to get back. ED stated that before the elopement incident on 06/20/2025, R1 was not wearing a safety bracelet. But after R1 returned, the facility ensured that R1 is wearing wander guard bracelet all the time. Med techs are checking three times a day to ensure R1 is wearing a wander guard bracelet. Continued on LIC809-C LPA reviewed R1’s Physician’s Report (LIC 602), dated 03/30/2025, R1 was non-ambulatory, had a primary diagnosis of Alzheimer's Dementia, was deemed not able to leave the facility unassisted. LPA reviewed R1’s Individualized Service Plan (ISP), dated 04/01/2025, which stated that R1 was ambulatory and unable to leave the community unsupervised. The ISP further stated that R1 was required to wear a safety bracelet while residing in the Assisted Living. LPA conducted a health and wellness check on R1 by visiting R1’s room. R1 stated that they did not have any recollection of whether they had exited the building alone without anyone accompanying them. R1 also stated that they liked to walk outside and inside the facility and use the elevators to go down to the first floor. R1 resided in the Assisted Living unit of the facility and was not wearing a safety bracelet at the time of the elopement. Facility staff did not ensure that R1 didn’t leave the facility unaccompanied, and a safety bracelet was not placed on R1’s arm prior to the elopement incident. Facility staff placed a wander guard bracelet on R1 only after the elopement incident occurred on 06/20/2025. A deficiency was cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and Plans of Correction were reviewed and developed with the Executive Director. A copy of this report and appeal rights were discussed and provided to the Executive Director, Stephanie Brice, whose signature on this form confirms receipt of these documents.