Incident investigation·October 22, 2025

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit to follow up regarding an incident report, which stated a resident had eloped from the facility. LPA met with Administrator (ADM) Michael Fountain. LPA explained the purpose of the visit. On October 16, 2025, the Department received an incident report (IR) from the facility. The IR stated, on October 15, 2025, around 7:20pm, medtech noticed R1 was not in their bedroom. After double checking the room, medtech alerted staff and initiated a thorough search of the community. The resident was located outside the community by a care giver and was safely escorted back inside. No injuries were observed. On October 17, 2025, LPA Manuel Monter interviewed Resident Services Director (RSD), Jmy Ramos. RSD stated R1 was found at target. (Based on a google Maps search, Target is 0.4 miles away from Westmont of Morgan hill.) RSD stated one of the care givers found him/her. RSD stated the care giver, Staff S4 had already clocked out, and happened to be at target, he/she recognized R1, at around R1 was found. RSD stated S4 saw R1 and recognized him/her. RSD stated R1 was found around 8:10pm. RSD stated R1 has wandering behavior. RSD stated, based on what she knows, R1 used to live at assisted living, and moved to memory care in July 2025. RSD stated R1 cannot leave the facility unassisted. RSD stated she isn't sure how R1 got out of the memory care, or which door, RSD stated the staff claimed they didn't hear the door alarms make a sound. RSD stated she tested the doors the next day, and the alarms did sound. RSD stated the executive director also tested the same day of the elopement and the alarm sounded. Page 1 Out of 3. On October 20, 2025, LPA Manuel Monter interviewed staff S1-S3. All staff interviewed stated R1 has exit seeking behavior. All staff interviewed stated they did not hear the delayed egress alarm activate/ring. S1 stated the day of the elopement, after taking R1 for a walk he/she took R1 back to his/her bedroom. S1 stated he/she went to pass out medications for the residents. S1 stated she started from the entrance of the memory care unit. S1 stated while she was going through her routine, she eventually got to R1, and R1 wasn’t there. S1 stated he/she doesn’t know how R1 exited the memory care unit. S2 stated on October 15, 2025, staff S1 and R1 went walking. S2 stated they came back around either, 6:40pm or 6:20pm. S2 stated S1 took R1 back to her room. S2 stated that is the last time he/she saw R1. S2 stated he/she was assisting a resident to bed when the elopement occurred. Staff S3 stated resident R1 is an exit seeker. S3 stated R1 is one of the main residents that tries to exit seek. S3 regarding the elopement: Around 7pm, was the last time he/she saw R1. S3 stated when he/she saw R1 in hallways, passing the dining room, headed to the TV. S3 stated he/she was going to use the restroom. S3 stated when he/she exited the bathroom, S1 asked if he/she has seen R1. LPA Monter interviewed Memory Care Coordinator, Rohit Singh, referred to as MCC. MCC stated R1 has sun downing and exit seeking behavior everyday. MCC stated R1 was assigned, in terms of groupings, to staff S1. MCC stated staff are supposed to supervise residents they are assigned to. The Department reviewed R1's Service plan, dated March 24, 2025. The service plan states, under the section, Wandering and Elopement, that R1 needs frequent supervision and redirection due to wandering outside and/or off community premises. Exits must be monitored due to elopement risk. Further more, the service plan states R1 has exit seeking behavior during the day and night; and R1 has prior history of elopement. Page 2 Out of 3. The Department reviewed R1's Physician's Report, dated April 8, 2025. The report states R1 has a neurocognitive disorder and cannot leave the facility unassisted. As a result, the department issued an immediate civil penalty of $500 for 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 Michael Fountain and a copy of the report was provided. Appeal Rights was provided. END OF REPORT Page 3 Out of 3