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Inspection visit

Incident investigation

TODOS SANTOS ASSISTED LIVING AND MEMORY CARELicense 0792008551 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 8/15/25 at 11:10 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a case management visit as a result of an elopement that occurred on 6/25/2025. LPA met with Executive Director David Clawson and explained the purpose of the visit. While at the facility on an unrelated incident LPA was made aware that R1 had eloped from the facility on 6/04/2025, 6/15/2025, 6/21/2025 and that R2 had eloped from the facility on 8/09/2025. Both R1 and R2 are memory care residents. All egress doors were operational at the time of elopements. On 08/09/2025 at around 1:30 pm, R2 stepped out of community and fell while walking. Paramedics were called and brought resident to John Muir Hospital for evaluation. Resident Came back next day, Concord Police, and R2's family were notified. On 6/21/25 staff reported that R1 was out on the street and was Immediately assisted and redirected back to the community. On 6/15/25 at approx. 7:45pm R1 was observed wandering outside of the building. Resident aide assisted resident back inside the building. On 6/04/25 staff reported that the memory care door alarm was on and R1 was out in the parking lot and was redirected back to memory care. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Facility did not prevent R1 from eloping The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Citations

5 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87219(h)(2)Type B

    The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement was not met as evidenced by: the memory care patio being locked from the inside not allowing access to residents in care.

  • 87303(a)Type B

    Maintain facility in clean, safe, sanitary condition

    The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by: LPA observed dirty dishes in the cabinet in the memory care rec room, as well as dirt on the walls and cabinets.

  • 87303(c)Type B

    Keep window screens clean and in repair

    All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: four windows in memory care were missing screens and at least two more had rips in their screens.

  • 87470(a)(2)(A)Type A

    Surfaces such as floors,... shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement was not met as evidenced by: The facility being informed on 7/7/25 that urine was found in the courtyard and not cleaning/sanitizing it until after 7/19/25.

  • 87468.2(a)(4)Type A

    Right to sufficient care and qualified staff

    (a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ...This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to multiple elopements by of residents in memory care which posed an immediate safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 15, 2025 inspection of TODOS SANTOS ASSISTED LIVING AND MEMORY CARE?

This was an other inspection of TODOS SANTOS ASSISTED LIVING AND MEMORY CARE on August 15, 2025. 1 citation were issued: 1 Type A (serious).

Were any citations issued to TODOS SANTOS ASSISTED LIVING AND MEMORY CARE on August 15, 2025?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be enco..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.