Follow-up on corrections·December 18, 2025

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced Case Management visit to follow up on an incident reported to Community Care Licensing. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Executive Director (ED) James Arp. Note, LPA did step out for lunch from 12pm-1pm. Community Care Licensing received an Incident Report on 12/05/25 in which it was reported that Resident #1 (R1) had eloped from the facility during the night and had been located by police approximately a block away from the facility, and taken to the hospital. Per the report, R1 sustained a laceration to the head, which was treated at the hospital. R1's responsible party and primary care physician were notified of the incident. LPA had also received a verbal report via phone call by ED Arp same day, where additional details regarding the incident were shared. Per the verbal report, R1 had a Diagnosis of Dementia and that exterior door alarms had failed, thus not notifying staff. Additionally, per ED Arp, the security guard that was supposed to be at the front entrance where R1 passed as they left the property was not at their post, and thus did not see R1 wander away either. During today's visit, LPA conducted a health and safety visit with R1 and provided consultation with ED Arp. The facility has moved R1 to the secured Memory Care unit post hospital discharge. The facility is working on updating/repairing their exterior door alarm systems and adding additional alarms to them. Additionally, the facility has increased staff presence at the front entrance to ensure someone is present at all times. The facility plans to implement trackable devices for at-risk residents for wandering/elopement in the coming months. [Continued on LIC 809-C] [Continued from LIC 809] Per review of R1's physician's report dated from May 2023, though R1 had no noted wandering/exit seeking behaviors, they were noted to be unable to leave the facility unassisted. Per review of R1's care assessment and service plan from November 2025, R1 required escort assistance to meals and activities due to their memory, but needed no assistance with guidance and redirection. Interviews with staff and R1's responsible party corroborated that R1 did not exhibit wandering behaviors prior to this incident. Interviews also corroborated that R1 received multiple staples to treat the laceration to their head sustained during their elopement. A type A deficiency was cited per Title 22 regulations and are noted on the attached LIC 809D. The citation is issued for the facility having been unable to meet the needs of R1 to ensure they did not leave the facility unassisted. As this is a violation that resulted in an injury to an individual in care, a Zero Tolerance Violation Civil Penalty is being assessed in the total amount of $500.00 and details are noted on the attached LIC 421IM. Additional Civil Penalties are under review by the Community Care Licensing (CCL) Department and may be assessed at a later date. A Technical Violation (TV) was also issued due to an accessible body of water located in the outdoor patio area of the ground floor. LPA explained the risks of residents who require additional supervision being around such fixtures. One deficiency was cited during the visit and one TV. An exit interview was conducted with Executive Director Arp to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.