Villas at Saratoga: Elopement Safety Failures - CA
The alarm was silent because there were no sensors installed along the path she took.
Federal inspectors documented the elopement at The Villas at Saratoga Skilled Nursing and Assisted Living following a complaint investigation completed August 20. The facility sits in a wooded, secluded setting in Saratoga, California, and houses both skilled nursing residents and assisted living residents in connected buildings. The resident, identified in inspection records only as Resident 1, lived in the assisted living wing.
The medical director walked inspectors through the elopement route on August 18. It began in AL2, a long hallway where assisted living residents live, passed through a door to a concrete stairway with a landing midway down, and continued past a metal grate roughly three feet high before reaching the forested area and, eventually, a public street. The medical director told inspectors the full path inside the building measured about five blocks. The stretch from the AL2 door to the street alone was at least two city blocks.
The wander guard Resident 1 wore was designed to trigger an alarm when she approached certain exits. It did not trigger because the exits along her path had no alarms installed.
During the same tour, at 3 p.m. on August 18, inspectors activated the alarm on the AL2 door themselves to see what would happen. The assisted living supervisor arrived four minutes and 45 seconds later. The medical director acknowledged the response time was long.
The assisted living supervisor, interviewed at 3:19 p.m. that day, said skilled nursing residents regularly come to AL2 to eat and attend activities. She said she did not know which of those residents were confused. If a confused resident came to her and asked for help, she said, the response was to call the nurse's station.
A review of the facility's full floor plan on August 20 found eleven exits in and around the building. Five exits on the first floor of the assisted living wing had no alarms at all.
The assistant director of nurses, interviewed that afternoon, said any unalarmed exit posed a danger to a confused resident, and that nursing staff should have been monitoring residents to prevent elopement. The facility's own elopement policy, last revised in April 2021, contained no guidance on how to prevent an elopement from occurring.
The inspection was classified under F0689, which covers the obligation to protect residents from accident hazards. Inspectors rated the harm level as minimal or potential, with few residents affected. The facility has 55 licensed beds.
What the record does not resolve is how long Resident 1 was outside before she was found, or what she encountered once she reached the street.
The forested path to the side street remains, by the facility's own floor plan, unalarmed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villas At Saratoga Skilled Nsg & Assisted Lvg from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 17, 2026 · Our methodology
THE VILLAS AT SARATOGA SKILLED NSG & ASSISTED LVG in SARATOGA, CA was cited for violations during a health inspection on August 20, 2025.
The alarm was silent because there were no sensors installed along the path she took.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.