Facility Evaluation Report

Licensing Program Analysts (LPA)s Hanna Gough and Rose Ruppert made an unannounced Case Management visit to follow-up on an Unusual Incident Report received in the Regional Office. LPAs were greeted and granted entry by the Concierge at 8am.

LPAs obtained the following documentation for Resident #1 (R1): Identification and Emergency Information Form, Physician's Report, Resident Appraisal, Assessment, Service Plan Detail and Facility Progress Notes. LPA reviewed three of three staff files and obtained a copy of an employee Notice of Disciplinary Action.

Per review of R1's Physician's Report dated 01/19/2022, R1 is diagnosed with Alzheimer's Disease. R1 is confused/ disoriented, has wandering behavior and is unable to leave the facility unassisted. The appraisal, dated 8/15/2024, states R1 wakes during the night searching for a family member. R1's Service Plan Detail, dated 2/11/2025 states R1 is exit seeking and a Care Conference was held with R1's Responsible Party on 2/14/2025 to discuss the updated care needs.

LPAs reviewed the Unusual Incident Report submitted to the Regional Office by the facility for an incident that occurred on 9/25/2025 at 4:50am. R1 activated the delayed egress alarm and walked away from the stairwell. The night staff silenced the stairwell alarm but did not reactivate stairwell alarm. R1 engaged with staff in a hallway before entering the stairwell and exiting the facility to the sidewalk.

Faciity staff initiated elopement procedures and were unable to locate R1 and contacted 9-1-1. During the call the dispatched Brea Police Department (PD) located R1 next door and returned R1 to the