Incident investigation·May 13, 2026

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management in response to Unusual Incident Report (UIR) the facility submitted. LPA met with Executive Director (ED) Joseph Villanueva and informed the reason for visit. UIR indicated that approximately 3:36 pm on February 28, 2026, resident (R1) was observed returning to the community from outside. Surveillance footage was reviewed and determined that R1 had left the facility unassisted through the main entrance door at approximately 2:58 pm. R1 cannot leave the facility unassisted. On this day, LPA obtained copies of resident roster and staff schedule. LPA inspected the entrance/exit doors with ED, conducted interviews and reviewed and obtained copies of R1's including but not limited to the following documents: Resident Information Form; LIC602A Physician's Report; Mini-Mental State Examination; Individualized Service Plan ED stated that at the time R1 left the facility, R1 was in Assisted Living. After the incident, R1 was provided 1:1 caregiver until R1 moved to Memory Care Unit about 2 week ago. ED also stated that the time the incident happened, the concierge/front desk staff left for few minutes. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Any repeat violation within 12 month period may result in civil penalty. Deficiency was discussed with the ED. Exit interview conducted. Appeal Rights and copy of this report provided.