Incident investigation·November 12, 2025

On November 12, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case- management visit in relation to an incident that occurred on 9/24/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported on September 24, 2025 at around 7:00pm, the police officers arrived to the facility with Resident 1 (R1). Licensee indicated R1 was found a block away from the facility and staff are unaware how R1 was able to leave unseen. When staff made rounds at 6:30pm, R1 was observed in his/her room. During the visit today, LPA interviewed assistant administrator, reviewed R1's file, and toured the facility to check the exit door alarms. LPA checked 5 exit doors on the first floor; of which 2 did not have alarms (including front door), 2 were off but working, 1 was working, and 1 that requires replacement. The exit door on the ramp was observed working but turned off. LPA checked 4 exit doors on the second floor, of which 3 were observed working, 1 observed not to have an alarm at all. Based on R1's physician report reviewed dated 12/21/24, R1 has dementia, is confused, disoriented, and unable to leave the facility unassisted. Although R1's physician's report indicated R1 does not have a wandering behavior, based on R1's reappraisal dated, 12/5/25, the facility noted R1 to be a wanderer and is confused and forgetful. According to the assistant administrator and the staff schedule reviewed from September 24, 2025, there were 3 caregivers on the first floor, 2 caregivers on the second floor and 1 med-tech throughout the entire facility during PM shift on 9/24/25. The assistant administrator indicated the staff did not see R1 elope from the facility. According to the assistant administrator and observations, the front entrance door does not have any locks or alarms and is unlocked 24/7. (continue to 809C). The Licensee failed to provide care and supervision as necessary to meet the needs of R1 after noting on R1's reappraisal that R1 is a wanderer, has confusion and forgetfulness which resulted into R1 leaving the facility unassisted without staff being aware. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). Report is reviewed with the assistant administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.