Incident investigation·November 5, 2025

On 11/05/2025 at 1:00 PM , Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident reported to Community Care Licensing Division (CCLD) on 10/22/2025 . Upon arrival, LPA met with Executive Director (ED) Angeles Sticka and explained the purpose of the visit. LPA obtained the following documents: Resident Roster, Resident Information Sheet, medical assessment dated (07/02/2025), Memory Care Staff schedule (week 10/12/25), In-Service "Elopement Drill" training staff sign-in sheet (dated 10/18/25 and 10/22/25), and Individualized Service Plan (dated 10/28/25). LPA interviewed Staff (S1) who stated that on 10/17/2025 , Resident (R1) eloped from the Memory Care (MC) unit. S1 reported that MC staff on duty did not observe R1 leaving the secured unit. According to S1, R1’s granddaughter was the individual who discovered that R1 was missing from their apartment and could not be located within the MC unit. S1 stated that staff immediately initiated the facility’s elopement protocol , which includes: conducting a search of the MC unit and resident apartments. Checking the Assisted Living (AL) apartments, common areas, and the remainder of the building. Conducting an external neighborhood search. Contacting 911 if the resident cannot be located. LIC809-C Continued... LIC809-C (Page 2) S1 reported that staff contacted the Berkeley Police Department, and shortly thereafter, the facility received a call from Agrodolce Osteria, a local restaurant located on Shattuck Avenue, informing staff that R1 was at their establishment. R1’s daughter retrieved R1 from the restaurant and returned them safely to the facility. S1 further stated that R1 has eloped twice to date, with the 10/17/2025 incident being the most recent occurrence. In response, the facility implemented door alarms on all emergency exits and conducted in-service training with MC staff on 10/18/2025 and 10/22/2025 regarding elopement procedures and resident supervision. S1 also indicated that a 1:1 companion was arranged for R1 for five days following the incident; however, the family declined to continue the service due to the cost. S1 added that R1 was later observed walking on Milvia Street, but staff are still unsure how R1 managed to exit the MC unit and the building. LPA reviewed R1’s Medical Assessment (MA), which indicated that R1 was able to leave the community unsupervised. LPA discussed this MA with S1, who confirmed that the response on the assessment was not accurate and did not reflect R1’s current condition or supervision needs. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided