complaint·April 7, 2026

During the brief call, the Administrator stated that Community Care Licensing would be receiving an incident report regarding a new resident, R1, who eloped on 11/26/25 or 11/27/25; the Administrator was uncertain of the date. The Administrator stated the elopement occurred in the early morning hours and that R1 had made it up the driveway and was just onto the parking lot area of the apartments next door, which is not part of the facility property. LPA received a faxed LIC 624 Unusual Incident/Injury Report on 12/03/25. The Resident Services Director (RSD) was noted as the one who submitted the report, and it had the signature of the Administrator. Review of the incident report states R1 “set off [their] wanderguard pendant alarm while attempting to exit through the front doors of the community. Community staff immediately responded and intercepted the resident in the foyer between the double doors.” The incident report did not match what was discovered through the complaint investigation nor what was reported during the phone discussion by the Administrator. The investigation also revealed the facility called Emergency Medical Services (EMS) due to R1’s behaviors, hallucinations and refusal to return to R1’s room. LPA reviewed the electronic health record (eHR) for R1 for the date of the incident, which stated R1 “wanderguard pendant went off by room 137 door. Medication Technician…went to check door. Resident was seen outside of community.” Additional note stated “…spotted resident far away from the community in front of another building…” An image of room 137’s location next to the side door was taken by LPA on 12/08/25 to confirm the location was not near the “front door.” LPA obtained a copy of the EMS report, which states: “Per staff on scene, Pt was wandering outside of the facility.” This also contradicts the initial report that “Community staff immediately responded and intercepted the resident in the foyer between the double doors.” During the visit on 12/11/25, an interview with RSD was conducted for another open complaint, but during interview LPA inquired about elopement incident. RSD’s account matched the events noted in the eHR. LPA asked RSD to explain why their interview did not match the LIC 624 Unusual Incident Report sent to LPA on 12/3/25; RSD was unsure. Prior to leaving, the Administrator stated that the RSD admitted copying an updated narrative from their regional office into the incident report and did not review what the update was. (Continued on 9099-C) page 2 A revised LIC 624 incident report was completed and provided to LPA on 12/11/25. Review of this new report still has an inaccurate narrative which states the resident “exit through the front doors of the community. Community staff…intercepted the resident in the driveway of community…” Front door is often referenced to the lobby front doors, and the resident was not found in the driveway of the community. A review of R1’s Physician Report record indicated that as of the date of the elopement, R1 was not diagnosed with Dementia but with Mild Cognitive Impairment (MCI). Therefore, the regulations regarding elopement reporting would not apply regarding contacting Licensing within 24 hours, and the reporting requirements of providing a report within seven days would apply. The reporting within the appropriate timeframe was done. However, due to the misleading and inaccurate narrative of the original and revised incident reports received on 12/03/25 and 12/11/25, a citation for Title 22, Section 87211(a)(1)(D) is warranted. Based on interviews and record review, while an incident was reported in the correct time frame via a written LIC 624, the document provided did not correctly account for the “nature of the event” as required. The preponderance of evidence has been met; therefore, the allegation is SUBSTANTIATED. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D) An exit interview was conducted; deficiency cited; a copy of this report and the appeal rights was provided. Page 3 On 12/08/25, LPA requested and reviewed four (4) staff files related to open complaints; no concerns were identified at that time. On 12/11/25, during a separate complaint visit, the LPA conducted staff and management interviews. During these interviews, staff and management reported that a staff member had recently been terminated after being found asleep by a supervisor who arrived early to follow up on internal reports of the staff sleeping on shift. The LPA requested and reviewed the additional staff file and confirmed, through internal email documentation and a “Corrective Counseling Documentation” dated 12/3/25, that a staff member was observed sleeping at approximately 4:00 a.m. on 12/03/25 and was terminated effective the same date for violating facility policy. The investigation revealed other staff were still present on the shift and there was no evidence that residents’ needs were not met. Based on the information obtained through interviews and record review, the allegation regarding staff sleeping was found to have occurred; however, the facility conducted an internal investigation, promptly addressed the concern, and terminated the involved staff member on the same date the incident was confirmed. There was no evidence found to prove the residents were at risk. In addition, although an elopement incident did occur, available documentation shows the facility responded in a timely manner and took measures to address the situation. The facility demonstrated corrective action and implemented steps to mitigate potential risks to residents. Therefore, the preponderance of evidence does not exist to prove that the alleged violations occurred as reported, and the allegation is deemed UNSUBSTANTIATED. Allegation: Staff are not properly assessing the residents It was alleged that the administration is allowing residents to move in or live at the facility that are not fit for assisted living. The reporting party stated that Resident 2 (R2) “belongs in a skilled nursing home according to [their] home health nurse.” Interviews from staff and residents claim the facility is accepting residents that have more care needs than previously accepted into Assisted Living including more cognitive issues and residents who are less ambulatory and have higher care needs. LPA reviewed records on 12/8/25 for four residents including R2, all residents had their physician’s report, appraisal/needs and services plan, and functional capabilities assessments. LPA reviewed a sampling of six (6) resident files on 01/27/26, all of which had pre-admission appraisals and current appraisal/needs and services plan as well as re-assessments. There was no indication in any of the documents that any of these residents require 24-hour nursing care, and none of them had any prohibited health conditions. Continue 9099-C Page 2 LPA attempted to review one chef’s timecard; however, they were unavailable because the chef is salaried. The Administrator stated they were not aware of any issues with the chef’s start times. Interviews conducted during the prior complaint and a review of Resident Council minutes (Nov. 2025–Feb. 2026) reflected that breakfast generally runs smoothly Thursday through Monday, but Tuesdays and Wednesdays commonly have delays; however, residents did not attribute the delays to the chef’s arrival time during interviews. Based on observation, interviews, and record review, the allegation that residents lack access to food after the dining room is closed and that proper breakfast is not provided due to the chef’s attendance is UNSUBSTANTIATED. There was not a preponderance of evidence to demonstrate that these allegations are occurring. An exit interview was conducted; a copy of this report was provided. Page 4 Interviews with Administrator and RSD revealed they conduct pre-placement appraisals with residents and obtain functional capabilities assessments prior to admission, in accordance with regulations. Additionally, the facility’s policy states residents will have a reassessment 30 days after move-in, and every six months after, or when a change of condition occurs. Based on the record review, residents admitted to the facility do not violate regulations regarding allowable conditions, abilities, needs, and services. At this time, a preponderance of evidence does not exist to support that the alleged violations occurred as reported; therefore, the allegation is deemed UNSUBSTANTIATED. Allegation: Residents not being provided adequate food service. It was alleged that residents lack access to food after the dining room closes and that proper breakfast items are not provided due to the chef arriving late. Regarding food availability after dining room hours, on 4/1/26 LPA arrived at 7:45 a.m. to observe the bistro. LPA noted fruit, Jell O, yogurt, chips, cookies, and leftover desserts, with additional items such as sandwiches, bananas, and string cheese added after lunch. Residents interviewed reported that food is available, though popular items may run out quickly. LPA also observed the bistro stocked with food items during visits on 11/25/25, 12/11/25, and 1/27/26, and verified that items were replenished after lunch during each visit. Resident Council minutes from November 2025 through February 2026 reflected one discussion regarding the bistro running out of sandwiches, bananas, and coffee after breakfast. The comment was not forwarded to the Administrator as a question or complaint. Residents interviewed by LPA stated that, in their observation, the bistro consistently has a small variety of food options. LPA could not confirm the allegation through observation or interviews at this time. Breakfast is scheduled for 7:00 a.m. According to the investigation, those who reported that the chef has arrived late also stated that when this occurs, residents still have access to cereal, toast, fruit, yogurt, and other bistro items. Continue 9099-C Page 3