Incident investigation·February 27, 2026

Licensing Program Analyst (LPA) De Leon conducted a Case Management- Incident Visit to the facility above. LPA met with Back up Administrator Jessica Bailey and explained the purpose of the visit. Community Care Licensing (CCL) received a self reported incident report from the facility dated 02/01/2026 for Resident (R1). Administrator Rachelle Tellez contacted LPA De Leon to report by telephone and followed up with a written incident report to CCL. R1 was able to elope from the facility and sustained a scrape to R1’s elbow and no other injuries were found.. R1 was located and brought back to the facility by staff. R1's LIC. 602 Physicians report stated that R1 can not leave the facility unassisted. This is the first time R1 had displayed exit seeking behaviors. CCL received another self reported incident report on 02/03/2026 for Resident 2 (R2). R2 was able to get out of the building and proceeded to go down the 2nd story stairwell when a nearby neighbor seen R2 contacted the facility staff and staff were able to redirect R2 back in the building. R2 did not elope off the property. The door alarm did go off, the two staff were on duty and Staff 1 (S1) was with another resident and Staff 2 (S2) had just gone in the elevator and did not hear the alarm go off. This is the first time R2 had displayed exiting seeking behaviors. On 02/01/2026 and 02/03/2026 by review of the staff schedules the facility was fully staffed on those days during those elopements.The facility does have alarmed exiting doors and the alarm was functioning properly. Exit interview conducted, deficiency cited, Civil Penalty assessed, copy of report and appeal rights printed for Administrator.