complaint·March 3, 2026

The Executive Director (ED) was able to identify residents in Memory Care Unit who have wandering, pacing and/or sundowning behaviors which included R1, R2 and R3. Review of these residents records confirmed the ED's statement. Staff (S1 and S2) stated residents rooms in Memory Care Unit are locked to prevent other residents from coming inside the rooms. FM1 and FM2 stated observing the residents' room locked and witnessing the staff unlocked the door from outside with a key to let them in. Although FM3 stated not witnessing R4's room locked, R4 does not have wandering behavior as indicated in R4's LIC602A Physician's Report. During inspection, LPA observed two of residents rooms' locked with residents inside the rooms. LPA knocked at one of the rooms and the resident who was inside tried but unable to open the door. The staff has to open the rooms with key to allow LPA in. Based on interviews and observation, the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.