Complaint Investigation Report

On October 3, 2025, LPA Steve Chang interviewed Administrator (ADM) Kellie Shearer. ADM stated resident R1 followed other families who were exiting the memory care unit and took elevator to the lobby area. R1 was found by staff in the lobby area on March 12, 2025 around 9:05PM. ADM stated after the incident, the facility put doorbell at the memory care unit entrance door/exit door and the facility members need to buzz in and buzz out of the memory care unit. ADM stated staff need to open and close the exit door of the memory care unit. ADM stated the facility checked R1 after the incident and did not found any injury.

On January 23, 2026, LPA Manuel Monter interviewed Staff S2-S6. 3 Out of 5 staff (S2, S3 S5) stated residents have attempted to elope from the memory care unit, but their attempts were thwarted by staff who intervened. S4 stated he/she is not aware of residents eloping from the memory care unit. S6 stated R1 did wander out of the memory care unit. S6 stated R1 managed to wander to the front door area, but the front desk was able to redirect R1 back to the memory care unit.

S6 stated R1 was able to get down, by following a family down the elevator. S6 stated this only happened once. S6 stated family’s used to have the card/fobs to leave the facility. S6 stated after R1 was able to get down, they changed the procedures. S6 stated family now has to ring the door bell to enter and needs to ask for staff assistance to exit.

On January 23, 2026, LPA Manuel Monter interviewed Assisted Living Director (ALD) Mayte Calderon. ALD stated she isn’t aware of any residents eloping from the facility. ALD stated residents have attempted to elope, but staff are able to redirect the residents who try to elope.

On February 5, 2026, LPA Manuel Monter interviewed Community Life Director (CLD) Barbra Fleig. CLD stated she is not aware of R1 eloping from the memory care unit. CLD state other residents have attempted to leave the memory care unit, but staff intervenes and returns the residents back to the memory care unit.

On February 5 & 9, 2026, LPA Manuel Monter interviewed Memory Care Director Daleht Miranda, referred to as S1 & Staff S7-S11. S1 stated she is aware when R1 had been found in the lobby by the front desk staff and redirect. 4 Out of 6 staff (S7-S10) stated they are not aware of any instance where a resident left the memory care unassisted and went to the first floor unassisted. S11 stated he/she is aware of an instance where a resident managed wander to the first floor but isn’t aware of the details. Page 2 Out of 6