Incident investigation·October 24, 2025

On 10/24/2025 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct Case Management Inspection in regards to incident report that was received on 10/22/2025. LPA met with Executive Director, Joan Newman and explained the reason for the visit. Based on the incident report received on 10/22/2025, resident (R1) was observed in the room attempting to open the window. R1 left the room and walk around the facility. Staff noticed that R1 was not in the common area and staff searched entire unit and found a window in the activity room had been pushed out and was open. During visit, LPA reviewed R1's file including physician's report, care notes, care plan, and incident report. R1's physician's report indicated that R1 cannot leave the facility unassisted. Interview with staff revealed R1 was anxious around 3:00PM and was pacing around the hallways. At around 3:40PM, care staff noticed R1 was missing. Staff conducted a head count and began to look for R1. Staff found R1 at a local shopping center about 20 minutes later. T he deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 . Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.