Incident investigation·November 7, 2025

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management visit to follow up on an incident report, which stated a resident had eloped from the facility. LPA met with Administrators (ADMs) Rose-Anne Roxas and Anshu Gupta. LPA stated the purpose of the visit. Elopement 10/29/2025 On 10/31/2025 the Department received an incident report regarding a resident (referred to as R1) who eloped from the facility on 10/29/2025. According to the report, on 10/29/2025 around 5:45PM, R1 'went outside of the facility unattended from his/her room while staff was helping the other residents in the dining room, when they heard the beeper, staff starting looking for the resident and they found out that R1 is not inside his/her room. They went outside the facility and saw R1 walking and took him back inside the facility." On 10/31/2025 Licensing Program Analyst (LPA) Maria 'Mita' Partoza interviewed Administrator (ADM) Anshu Gupta. ADM stated R1 eloped from the facility between 5:45PM and 5:47PM. ADM stated R1 had finished eating dinner, stood up and went to his/her room. ADM stated a staff member went with R1 to his/her room and placed a tab alarm device on R1, and the staff then went back to the kitchen to assist with other residents. ADM stated there were additional staff on shift, including the cook when the elopement occurred. ADM initially stated it took staff '3 to 4 minutes' to respond to the alarm (beeper). ADM then stated staff responded immediately to the alarm (beeper). ADM stated she observed R1 at the facility when she arrived at approximately 6:00PM. ADM stated R1 was located on the next street over from the facility. Page 1 of 2 On 11/5/2025 LPA Tarin interviewed ADM Anshu Gupta. ADM stated on 10/29/2025 R1 had removed his/her tab alarm, but R1 was also wearing a Wanderguard, which alarmed when R1 exited the facility. ADM stated staff located R1 on the sidewalk corner of Chanticleer Ave and Brommer Street. ADM stated R1 walked right onto Brommer Street and walked to Chanticleer Ave, where staff found him/her. ADM stated R1 was returned back to the facility and R1's responsibly parties were informed. ADM states R1 was not injured during the elopement. Based on a Google Map search, staff located R1 on the sidewalk of a 4 way intersection approximately 400 feet from the facility. On 11/7/2025, LPA interviewed Administrator (ADM) Rose-Anne Roxas. ADM stated R1 walked out through the facility front door on 10/29/2025. ADM demonstrated the path which R1 took when he/she eloped from the facility on 10/29/2025. ADM walked LPA Tarin through R1's elopement path, through the facility front door, and out to the front of the facility, which leads to Brommer Ave. LPA observed there is no sidewalk leading to Chanticleer Ave, only a bike lane, next to 2 street lanes. LPA interviewed R1. R1 did not provide additional information due to neurocognitive disorder. Based on a review of R1’s Physician’s report, dated 10/2/2025, R1 has neurocognitive disorder and cannot leave the facility unsupervised. R1's Needs and Service Plan dated 10/14/2025, R1 is "forgetful, disoriented, fall risk, and increased cognitive decline." A Deficiency was cited per California Code of Regulations, Title 22 during today’s visit, see LIC809-D. An exit interview was conducted with Administrators Rose-Anne Roxas and Anshu Gupta. A copy of this report and appeal rights were provided.