Incident investigation·April 22, 2026

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and met with Rachael Robert, Resident Care Coordinator (RCC). LPA stated the reason of the inspection. LPA and RCC discussed the following (2) recent incident reports submitted to the Department. Resident (R1) left the facility unassisted on April 19, 2026 (5:05 pm) by exiting through the back gate. (R1) was brought back by a nearby neighbor approximately (20) minutes later. The RCC stated staff present during the incident have been held accountable due to not following all protocols when an alarm is activated. The RCC stated the protocols are that staff is to look at the monitor which shows interior/exterior camera footage, communicate with other staff by radio, and allow the alarm to run until the resident is located. The RCC explained that a staff was leaving at the time the alarm was activated, but the alarm was immediately shut off which caused some staff to think (R1) had already been located. A follow up in-service staff training was held on April 21, 2026 to address the miscommunication error and not following proper protocols. In addition, (1) staff received a disciplinary action on April 20, 2026. LPA and the RCC toured the building and observed/tested multiple exit doors. The RCC demonstrated how to properly ensure the egress door is locked, after being activated, including waiting a few seconds for the door to close/lock and staff possibly needing to enter a code before walking away from the exit door. The RCC stated daily radio checks are completed and proper protocols are discussed in daily Stand-up meetings with staff. LPA reviewed (R1's) physician's report which notes (R1) is not able to leave the facility unsupervised due to their primary diagnosis. The RCC stated (R1) likes to walk around inside the community and outside as well, and the new staff was not familiar with (R1's) behavior due to being off work for an extended period due to personal reasons. *cont on 809C-1.. 809C-1. LPA and the RCC discussed resident (R2) who had an unwitnessed fall on April 12, 2026 (4:00 pm) after slipping on the floor in their resident bathroom. (R2) requested to go to the Emergency Room due to complaints of back pain and a leaking colostomy bag. (R2) returned the same day with a new colostomy bag and continued to receive Home Health services, which include Physical Therapy. (R2) continues to receive checks (4x/shift) and staff will promptly report any changes in condition to the primary care physician. The RCC stated (R2) was sent out to the hospital on April 19, 2026, due to an issue related to the colostomy bag and is scheduled to return to the community later today, possibly with a bed alarm. The facility promptly sent (R2) out for further medical treatment after communicating with Home Health. Per California Code of Regulations Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited related to resident (R1), on the 809-D page. Exit interview. Copy of report and appeal rights provided.