Incident investigation·September 4, 2025

At approximately 12:00 PM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Lauren Cottman. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 08/27/2025. The report stated that on 08/25/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community shortly after 5:30 PM, by exiting emergency exit door on the right side of the 1 st floor elevator as staff was returning residents to 2 nd and 3 rd floor apartments after dinner. At approximately 7:30 PM staff was unable to locate R1 and notified ED, while interior & exterior search was conducted. At approximately 8:15pm Med Tech contacted EMS and was informed fire department brought R1 to hospital after finding near fire house confused. R1 was assessed at hospital, finding no injuries and discharged back to community same evening. After further check of facility, two doors on the 1 st floor were found unlocked and one alarm found on emergency exit turned off. PCP and family were notified. LPA was provided; staff signed training for elopements, plan to keep residents safe from future risk, and investigation documents. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) LPA also obtained updated service plan and notes from care conference. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.