Incident investigation·April 28, 2026

04/28/2026; Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Melon Rivera and Business Manager, Karina Vazquez. The purpose of the visit was to follow up on a special incident report (SIR) that was self-submitted to Community Care Licensing (CCL). CCL received an SIR on 04/22/2026 stating at approximately 6:30PM on 04/15/2026, staff were alerted that resident (R1) was not in their designated area. At the time, two caregivers were actively assisting another resident with care needs, and a medication technician was on a scheduled break. Caregiver assigned to monitor the floor had temporarily stepped away to support care tasks, resulting in a brief lapse in direct supervision. Staff heard an alarm sounding and cleared it without verifying which resident had triggered it. Once R1s absence was identified, staff initiated a systematic search of the unit. When the resident was not located, a Code Silver was activated. During the search, staff received information by bystanders reporting that the resident had been seen past Novato Hamilton Station. Staff located the resident off site with two individuals who had assisted R1 to their vehicle. R1 was escorted back to the community. Per conversation with Business Manager, R1 was missing for approximately 30-45 minutes. R1 is a resident in memory care and a high-risk for elopement. In-service training for elopement was conducted for care staff on 04/21/2026. 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 Business Manager.