Incident investigation·October 31, 2025

On 10/31/2025 at 9:30AM, Licensing Program Analysts (LPAs) G. Luk and A. Christy arrived unannounced to conduct Case Management Inspection in regards to incident report. LPA met with Business Office Director, Claudia Redditt and explained the reason for the visit. Based on the incident report, staff (S1) that was heading to work observed resident (R1) was walking down the street from the facility. S1 redirected R1 and escorted R1 back to the facility. R1 did not sustain any injuries. R1's doctor and family was notified. During visit, LPA reviewed R1's file including physician's report, care plan, and incident report. R1's physician's report dated 1/6/2025 stated that R1 is unable to leave the facility unassisted. Interview with staff revealed that R1 was wearing a roam alert bracelet and doors would alarm when R1 walks through the doors. S2 stated at the time of incident, the front door and the door to courtyard was alarmed one after another. When S3 cleared the alarm for the front door, R1 had already left the community. S1 escorted R1 back to the facility. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.