Non-compliance follow-up·December 22, 2025

A Non-Compliance conference was conducted on 12/22/2025 at Sacramento North Regional Office via Microsoft Teams. Present in the meeting were facility’s representatives Mary Roberts, Operating Officer, Administrator Cathy Dustin, Acting Regional Manager (RM), Laura Munoz, Licensing Program Manager (LPM), Troy Ordonez and Licensing Program Analyst (LPA), Graham Gunby. Department reviewed the purpose of the NCC, emphasizing the responsibility of the Licensee to ensure the health, safety, and personal rights of residents in care and to maintain substantial compliance with applicable licensing laws and regulations. The Department discussed the facility’s compliance history, including a substantiated complaint in which staff failed to prevent a resident from leaving the facility unassisted, resulting in citations and civil penalties. The Department noted that the appeal of the citation was denied. The Department identified the following areas of concern requiring corrective action submitted by 01/22/2026 · Acceptance and retention of residents with elopement or exit seeking behaviors beyond the facility’s ability to safely supervise. · Failure to consistently update residents Needs and Services Plans and reappraisals to reflect changes in condition. · Insufficient staff training related to elopement risk, exit-seeking behaviors, and supervision requirements. · Administrator oversight, accountability, and fulfillment of required duties. · Improper use, adjustment, or deactivation of door alarms intended to monitor resident movement. *Continued on LIC809-C* The Department discussed the importance of maintaining accurate assessments, conducting timely reappraisals, and ensuring staff are adequately trained to respond to residents’ changing needs. The Licensee/Administrator was advised that failure to implement effective supervision practices and training places residents at risk and may result in increased enforcement action, including enhanced monitoring or administrative action The Department informed the Licensee that a written compliance plan is required and must address the following: · A comprehensive staff training plan specific to the care and supervision of residents who exhibit exit-seeking or elopement behaviors, including identification of who will conduct the training, how training will be monitored, and how completion will be documented. · Administrator completion of reappraisal training through an approved vendor, with documentation of training completion submitted to the Department. · A plan to ensure all door alarms are operational, audible, and routinely monitored. · A plan to ensure staff are informed of residents’ needs and any changes in condition in a timely manner The Licensee was advised that the Department may increase monitoring to verify implementation and ongoing compliance. The NCC was concluded with an explanation that failure to achieve and maintain compliance may result in further enforcement action.