Incident investigation·January 29, 2026

On 01/29/2026 at 9:30 AM, Licensing Program Analyst (LPA) Ardalan Gharachorloo arrived unannounced to conduct a case management visit in response to an incident report received on 01/28/2026 regarding R1 leaving the facility unattended at approximately 3:00 PM. LPA met with Administrator Samuel Tet and explained the purpose of the visit. On 01/28/2026 LPA received an incident report stating that R1 left the facility unattended around 3:00 PM. Staff contacted 911 immediately and Alameda county police began search for resident. Administrator stated "Oakland Police department located R1 and transported the resident to ER". R1 was admitted to Sutter Health Hopsital in Castro Valley. The Administrator stated that he went to the ER on 01/28/2026 to check on the resident. LPA reviewed R1's records including but limited to Physician Report and Needs and Services Plan. R1 is diagnosed with Dementia and requires supervision and may not be left unattended. LPA also observed that the door alarm was not operational at the time of the incident. Administrator fixed the alarm on the door during the visit. The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.