Incident investigation·September 23, 2025

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/23/25 to conduct a case management inspection to follow up on a recent AWOL for R1 at the facility. LPA met with Administrator Stephen MacDonald and explained the purpose of the visit. R1’s AWOL Incident- The facility submitted a completed Unusual Incident/Injury Report (LIC624) on 09/15/25 regarding resident (R1) leaving the facility unattended on 09/12/25 , at approximately 1430. Per incident report, R1 was brought back to the facility uninjured by neighbor. Facility notified R1s doctor and family regarding this AWOL incident. R1's physician's report dated 01/14/25 indicates that resident has diagnosis of Mild Cognitive Impairment (MCI) and cannot leave the facility unassisted. Although no injuries resulted from R1s AWOL incident, R1s LIC602 indicated they were unable to leave the facility unassisted. Facility staff did not provide care and supervision for R1 resulting in R1 leaving the facility unassisted. Based on gathered information, violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report, appeal rights have been provided .