Incident investigation·July 23, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with executive assistant Olivia Sterba and explained the purpose of the visit. LPA Moleski reviewed an incident report which was received by the Community Care Licensing Division (CCLD) on 7/19/25. According to the incident report, on that same date, a resident (R1) was discovered missing at the time of their evening medication pass, around 5 p.m. Facility staff reviewed surveillance footage and observed that R1 left the facility that day at 1:33 p.m., according to the incident report. In an interview, the facility's director of resident services (S1) said they called 911 after searching for R1, and were informed that police had already contacted R1 in a residential neighborhood following reports made by nearby citizens. S1 said that R1 was found without their pants or shoes on, and had blisters on their feet. In an interview, R1 said they normally go for walks with their "friend." S1 said that R1 has a third-party companion from 1 p.m. to 5 p.m. daily who was absent on 7/19/25. LPA Moleski reviewed R1's medical assessment. The medical assessment did not contain some information which is found on CCLD's LIC 602, such as the ability of the resident to travel in the community unsupervised. The resident's primary diagnosis was listed as "possible major neurocognitive disorder due to Alzheimer's disease." Active problems were identified as "visual hallucination," "osteoporosis," and "lumbar muscle strain." [continued on 809-C] LPA Moleski reviewed a needs and services plan for R1 dated 3/19/25. R1 is "unable to leave the building unattended," and staff are to "provide assistance to resident when exiting the building," according to the needs and services plan. The needs and services plan also identified R1 as "non-ambulatory" and requiring support from staff "as appropriate due to resident's non-ambulatory status." LPA Moleski reviewed the footage taken of the incident. LPA Moleski observed a staff member (S2) at the front desk at the time R1 left the facility. S2 appeared to be looking down, and did not appear to notice R1 as they walked out the front door. This facility is hereby cited per Health and Safety Code Section 1569.312(d). Appeal rights and a copy of this report were left with Sterba.