Follow-up on corrections·January 15, 2026

01/16/2026 10:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with administrator Editha McCullogh. Today’s visit is regarding an incident that occurred on 01/09/2026 and was reported to licensing on 01/12/2026. It was reported that on 01/09/2026 6:53 PM Resident 1 (r1) was found outside by Med Tech who noted that the front door had not been properly closed. R1was discovered sitting in their wheelchair in the parking lot's ditch but was unharmed. Resident Care Coordinator was immediately informed, and resident's POA, was notified. R1 was placed on 30-minute checks and routine checks are being conducted to ensure the front lobby door is latched at all times. During the course of the investigation, it was learned that another resident had been transported back to the facility from hospital and staff were called at 6:52 PM to retrieve this resident. The transportation driver informed staff that they saw a wheelchair outside and staff found R1 sitting in their wheelchair. Staff had last seen R1 inside of the facility at 6:30 PM. Continued on LIC809-C During LPA’s tour of the facility on 01/15/2025 LPA observed that the interior door with key pad entrance was malfunctioning. When staff entered the code the door opened and dis-alarmed. When staff let go of the door LPA observed that the door did not automatically close and latch though the keypad read that the door was secured. This is likely how R1 was able to enter the facility lobby through the unlatched door. Staff did not provide adequate care and supervision to R1 to prevent them from exiting the secured door to the lobby and exiting the exterior lobby door at night which adversely affects the health and safety of R1 due to darkness and street traffic in the area. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to the administrator.