Complaint Investigation Report

LPA attempted to interview R1 on May 14, 2025. R1 was unable to answer qualifying questions. R1 was unable to state the date or time. LPA then asked R1 basic questions regarding leaving the facility unattended. R1 stated that they have left the facility in the past but not recently.

LPA interviewed R2 who stated that they have lived at the facility too long. R2 stated that they were recently thinking about walking across the street and catching a bus. R2 stated that in the past when they tried to leave the facility unsupervised a staff member yelled at them to get their walker. R2 stated that last month they left the facility and walked to the intersection by themselves.

LPA interviewed S1 who stated that the memory care unit was conducting an "elopement drill" right before the incident occurred with R1. S1 stated that the caregiver assigned to R1's section claimed that they "cleared their section." S1 stated that the egress door alarm sounded a short time after and the staff conducted a head count of residents. S1 stated that as they were driving away from the facility they saw R1 outside on the sidewalk area. S1 stated that they placed R1 in their car and drove them back to the facility. S1 stated R1 had no injuries and they estimate that R1 was out of the facility for approximately 10 minutes before R1 was located.

LPA interviewed S2 who stated that while driving to work on April 26, 2025 they saw R2 walking towards the street intersection of Olympic Parkway and East Palomar Street. S2 stated that they were worried and immediately called their supervisor to advise them where R2 was located. S2 stated that they do not believe R2 had any injuries as a result of the elopement. S2 stated that R2 lived in the assisted living section of the facility and has eloped from the facility more then three times.

LPA interviewed Outside Source 1(OS1) who stated that the facility staff called them immediately after the incident and advised OS1 that R1 "got out of the facility through the back." OS1 stated that the Director contacted OS1 the following day and was apologetic for what occurred. OS1 stated that they do not believe it was a major incident since their were no injuries and R1 simply slipped out. OS1 stated that R1 has never eloped before and they have full confidence in the facility staff.