Incident investigation·September 3, 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 received an incident report from this facility on 6/24/25. LPA Moleski previously discussed the incident report with staff on 7/8/25. However, due to time constraints, LPA Moleski was unable to complete a case management visit regarding this incident at that time. The incident report described above states that a resident (R1) was discovered missing around 7:20 p.m. on 6/23/25. R1 lives in a delayed-egress memory care cottage equipped with door alarms. The incident report stated that staff searched the cottage, but could not find R1. Staff continued to search the surrounding areas, and R1 was found in a nearby parking lot off facility property around 7:45 p.m., according to the incident report. LPA Moleski spoke with R1 during his visit on 7/8/25. R1 did not remember the incident. LPA Moleski reviewed R1's LIC 602, dated 5/23/25, and observed that R1 has a diagnosis of mild cognitive impairment and has a history of seizures. R1 is not permitted to leave the facility unassisted, according to their LIC 602. R1 suffers from confusion and has an unsteady gait, according to the LIC 602. R1 is nonambulatory, per the 602. R1's pre-admission appraisal, dated 6/11/25, indicates that R1 needs special observation and/or night supervision due confusion, forgetfulness, and/or wandering. R1's LIC 602 addendum, dated 5/23/25, indicates that R1 suffers from hallucinations. [continued on 809-C] LPA Moleski interviewed the cottage's on-duty caregiver (S1) during his visit on 7/8/25 and also on 9/3/25. S1 said that they were sitting near the front doors of the cottage prior to R1 being discovered missing. However, S1 said they heard no alarms, and did not see R1 leave. 22 CCR Section 87705(e)(5) requires that "facility staff shall ensure the continued safety of residents [with a dementia diagnosis] if they wander away from the facility..." Additionally, HSC Section 1569.312(d) requires that staff remain "aware of the resident's general whereabouts..." at all times. This facility is hereby cited per HSC Section 1569.312(d). As this deficiency involves an absence of supervision, an immediate civil penalty in the amount of $500 is hereby assessed. An exit interview was held with Dial. Appeal rights and a copy of this report were left with Dial.