Incident investigation·August 21, 2025

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection. LPA arrived to the facility and was greeted by staff. Licensees Cecilia Ganzon and Aurelia Renta were contacted and arrived later to the facility to conduct today's inspection. The purpose of this case management inspection is to follow up on a self report incident report submit to Community Care Licensing (CCL). CCL received a self reported incident report on 8/18/2025 reporting an incident of AWOL that occurred on 8/17/25 when resident (R1), AWOL'd the facility during a big group of visitors that came to visit another resident. At approximate 2:45 pm staff (S1) noted that R1 was gone, staff went outside to look around the neighborhood. At 3:53pm Kaiser ambulance called the facility to notify them that resident was brought to ER. Honda Vallejo observed resident and called the ambulance. At 4:30pm resident was discharged back to the facility. After resident was located an identification bracelet was provided to resident and responsible parties were notified. After learning of the incident, LPA contacted the facility on 8/18/2025 and spoke to Administrator to request additional documentation including R1's physician report (LIC 602), care plan and AWOL policy. During today's inspection, LPA reviewed records and conducted interviews with Licensee and staff. Facilities Polices and Procedure regarding AWOL/Elopement were not followed. R1 does not have a medical assessment since 9/29/23, R1 has a diagnosis of dementia and is not allowed to leave the facility unassisted. Also, needs or service plan dated 8/17/25 needs to be reviewed and updated. LPA learned after reviewing LIC500 Personnel Report that S1 started working at 3pm and there was another staff (S2) who was working from 6am-3pm to care and supervise 12 residents in care, which conflicts with incident report data. Based on interviews with the Licensee and records review, It is unclear the time when R1 left the facility, but facility visitor's log for the date of 8/17/25 indicates that big group of visitors arrived at 1:10pm. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Licensees and copy of report given.