Incident investigation·May 6, 2026

05/06/2026, Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Scott Davis. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 04/23/2026 stating on 04/16/2026 at approximately 6:00PM resident (R1) was observed to be missing from Memory Care. R1 was located at Novato High School by an individual and returned to the community. R1 was unaccounted for approximately one hour. Per conversation with Memory Care Director, R1 was wandering around when another resident who resides in assisted living was going to see their spouse who lives in memory care. When the resident opened the door to get into memory care, lead to R1 getting out as the door was momentarily open. Facility conducted an in-service training on elopement drills on 04/29/2026 for caregivers on AM and PM shift. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights provided to Executive Director.