Incident investigation·July 17, 2025

At approximately 10:05 AM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Candice Moses and Mindy Melendez, Chief Strategy Officer (CSO). The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). LPA Nakagawa received a call from Administrator on 07/07/2025 to self-report an incident that occurred on 07/06/2025; incident report was filed on 07/09/2025. The report stated that on 07/06/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community sometime before 9:45 PM. Paramedics called the overnight phone asking if the facility had a resident (R1). Staff were unaware of R1’s elopement as no alarms were set off. R1 was identified and paramedics stated they had taken R1 to Vaca Valley emergency room. Administrator, hospice and family were notified. R1 was discharged from hospital the following day. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with Dementia and is unable to leave the facility unassisted. (Deficiency cited) Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision. See LIC809-D for Deficiency. Exit interview conducted with Administrator and CSO and a copy of this report along with LIC811 (Confidential Names) was provided .