- Date
- 1/12/2026
- Report number
- CALMS - 00101470
- Type
- Licensing Violation
- Level
- 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance
- Allegation
- Failed to maintain a safe physical environment
- Result
- Substantiated
- Findings
- Resident 1 eloped from a secured facility by exiting behind visitors who had held the door open. Resident 1 remained unsupervised for approximately 45 to 60 minutes, traveled approximately half a mile from the facility, and was exposed to imminent hazards by crossing a four-lane highway and nearly falling into an open hole in a construction zone. someone is in there.
Staff 1 stated that there were alarms on the doors that “chimed” on tablets carried by caregivers, which were intended to prompt staff to check who had entered or exited; however, the sound on the tablets had been turned down and staff were not checking.
The facility failed to exercise reasonable precautions, which is a violation of administrative rules.