CONCORD -- An adult care home was not supervising patients, and its front door had no working alarm as required on the day one of its dementia patients slipped outside and later died of heat stroke, according to a state investigation report released Thursday.

The state Department of Social Services investigation offers the first concrete details of what went wrong on Sept. 30, when 86-year-old Yolanda Membreno walked out of Julia's Home and was found dead hours later in a playground 100 yards away.

Inspectors with the Community Care Licensing Division, which regulates adult care facilities, reviewed police and coroner reports and interviewed staff during visits on Jan. 8 and 22. Key findings include:

  • Two workers were doing laundry and cooking, and no one was supervising the residents at the six-bed facility.

  • The home failed to report to the state previous incidents in which Membreno left.

  • The home admitted to not informing family members of the details of Membreno's death.

  • Membreno's death was preventable.

    "It put those patients at risk, and they knew it," Membreno's daughter-in-law, Sabrina Sanchez, said of the care home. "This could have been absolutely avoided."

    As a result of the investigation, Julia's Home was cited for violating five state codes and was subsequently fined $1,050 for not submitting plans to correct the violations by Jan. 31. Roy Roberto, who was the administrator of Julia's Home in September, would not comment Thursday. He said he is no longer affiliated with the facility but would not elaborate.

    Michael Cardoza, an attorney for the Membreno family, said the fine was "tantamount to a slap on the wrist. What's the point? It's not much of a deterrent to these homes to clean up their act and make sure their homes are run safely and properly according to our laws. A human life was taken."

    Cardoza said he has pushed the Contra Costa District Attorney's Office to prosecute those who run the care facility.

    Workers at Julia's Home searched for Membreno for more than an hour before contacting police. Adult care facilities are not required by law to contact police when patients vanish. Last week, Assemblywoman Joan Buchanan, D-San Ramon, introduced a bill that would make such notification to police -- and to family members -- a requirement.

    David DeBolt covers Concord and Clayton. Contact him at 925-943-8048. Follow him at Twitter.com/daviddebolt.