Incident investigation·April 1, 2026

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports submitted to the department. LPA was greeted and granted entry into the facility and explained the reason for the visit. Incident report dated 03/18/2026 indicated Resident 1 (R1) left the facility around 7:00 PM and returned at 9:40 PM. Resident was assessed and no injuries noted. Resident was noted to be exit seeking and was provided a wander guard on 03/17/2026 however the resident removed the device. Resident is on the facility elopement list at front desk as unable to leave the facility. There are staff present at front desk until 9:00 PM. Incident report dated 03/24/2026 indicated R1 had eloped out of the community and was returned to the facility by a bystander who observed the resident outside the facility. Resident returned at 3:00 PM. It is unknown what time the resident left. Facility placed a one on one companion with the resident and a care plan will be conducted for next steps with resident. Resident is diagnosed with MCI and physician reports dated 10/02/2022 and 03/24/2026 show resident is not allowed to leave the facility unassisted. Resident had a prior elopement in December 2022. LPA observed the resident sitting on a bench near the facility exit without the one on one companion. LPA spoke with resident who stated was going to be leaving for a medical appointment with family. Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided as well as appeal rights.