Incident investigation·July 8, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator James Dial and explained the purpose of the visit. LPA Moleski reviewed an internal incident report which was provided by facility staff on 06/20/25 during a complaint investigation visit. The internal incident report described a resident (R1) engaged in "hazardous wandering" on 6/3/25. According to the internal incident report, R1 was supervised, but had left the community. Dial said R1 was walking along the sidewalk with staff, and 911 was called as a result because R1 was not redirectable. R1 has a diagnosis of dementia and suffers from confusion and wandering behaviors, according to R1's LIC 602, which is dated 5/31/25. LPA Moleski reviewed CCLD fax and email records and observed no incident report was received regarding this incident. The facility's resident care coordinator (S1) said an incident report was not submitted to CCLD regarding this incident. Dial agreed that an incident report should have been submitted regarding this incident. Dial said there was a second incident on 6/7/25 wherein R1 left their cottage, but did not leave the facility grounds. LPA Moleski asked Dial to provide the internal incident report from this second incident when possible. Dial agreed to do so. This facility is hereby cited per 22 CCR Section 87211(a)(1)(D). An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.