Incident investigation·May 13, 2026

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Case Management investigation and was greeted by staff, Licensee, Josephine Credo arrived later. On 5/12/26 the department received an email from the licensee pertaining to resident (R1). On 5/11/26, R1 was victim of a hit-and-run accident that resulted in R1's passed away. According to Licensee, on 5/11/26 at approximately 12:30pm, R1 informed a lead staff member about their intentions to travel to downtown Santa Rosa and planning on returning in the evening, R1 signed the facility sign-in/sign-out form log at 12:45pm, then a t approximately 2:45pm - 3:00 PM, staff noticed unusual traffic congestion on street due to the sirens in the neighborhood and reports of a person in a wheelchair being struck by a vehicle, staff became concerned and one staff member went to investigate along with Administrator, when they approached the scene identified R1's wheelchair and confirmed that the resident had passed away. The Administrator identified themselves to the police and notified responsible parties. As of today, the facility has not received an official update from the Santa Rosa Police Department case# 26-4898. During today's visit, LPA conducted interviews, reviewed documents, and received copies of documents. Based on records review, LPA was provided with sign-in/sign-out form including R1's sign off time and most recent R1's physician report (LIC602) dated 4/14/2026. According to R1's physician indicated that they were not at risk of harm due to their cognitive condition when leaving the facility unsupervised; Therefore, R1 was permitted to leave the facility unassisted. Licensee agreed to obtain R1's Death Certificate to provide to CCL once received. No deficiencies cited during this visit. Exit interview conducted with Licensee and copy of this report was given.