Incident investigation·September 10, 2025

Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Karina Vasquez, Business Manager and Jose Acumabig, Executive Director. 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 09/09/2025 Incident Report states on 09/03/2025 at approximately 1:55PM, a code silver was initiated for resident (R1) after R1 was found to be missing from both the common area and their assigned room within memory care section of the community. A coordinated response was launched involving approximately 12-18 staff members who assembled in the lobby and divided into search teams. Staff conducted a thorough search of all floors within the community and extended their efforts to surrounding outdoor areas, including the amphitheater and seashore landing - locations where R1 is known to frequent visit with their daughter. Search teams utilized various methods, including traveling on foot, in personal vehicles, and via the community transport bus. R1 was located approximately 0.5 miles from the community by two care staff members. Upon approach, R1 displayed resistance and agitation, continuing to walk with staff following closely behind for an additional 0.5 miles. Staff were eventually able to redirect R1s attention and safely escort R1 back to the community. Upon return, R1 was offered an antianxiety medication, which R1 accepted and tolerated well with 120 ml of water. No difficulty swallowing was observed. R1 denied any pain or discomfort, and no abnormalities in gait were noted during assessment. (Deficiency Cited) Per conversation with Business Manager and Health Care Director, they believe R1 got out from one of the back doors in memory care. R1 was gone for approximately one hour without supervision. The door alarm was activated when R1 left the facility. The alarm alerted staff, who went to go check the door and didn't observe any residents near so staff closed the door and reset the alarm. Facility conducted an in service training regarding elopement on 09/04/2025 and 09/09/2025. Per R1s physician's report (LIC602) R1 is diagnosed with dementia and is unable to leave facility unassisted. See LIC809-D for Deficiency. Exit interview conducted with Administrator and a copy of this report along with LIC811 (Confidential Names) was provided .