Incident investigation·August 20, 2025

Licensing Program Analyst (LPA) Alviso conducted a case management inspection, on 8/20/2025 at approximately 9:40am, and met with Executive Director, James Homer. This case management is to review resident incidents' of R1 AWOLs/wandering away from the facility. LPA reviewed resident, R!, records, and obtained additional information on incidents. R1 resides in assisted living area of the building. Resident R1 who uses a four wheeled walker that has a wander-guard attached to it. Wander-guard is to alert facility staff if resident wanders out of any exit door/gate. R1 is not to be in the community/out of the facility unsupervised per medical assessment, and review of resident records. R1 exited and AWOL the facility without staff’s knowledge on 8/14/25, 8/2/25, 6/6/25, and 5/8/25. On 8/14/25 , resident wandered away and an individual saw R1 and contacted the Police. Staff had not located R1 and called 911; R1 was returned to the community by the Police department. On 8/2/25 R1 was not in their room when staff came to take them to their dinner meal, staff searched inside and outside the facility, when a staff observed R1 walking into the front entrance of the building on their own. On 6/6/25 R1 exited the facility without staff’s knowledge, R1 was observed outside by the trash cans/dumpster by a maintenance staff who was arriving to work. Staff parked their vehicle and went and found R1 sitting in a staff’s parked car. Facility staff redirected R1 back into the facility. On 5/8/25 staff found R1 wandering around outside the facility. Regulation Reappraisals- 87463, this shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. Behavioral expression, as defined in Section 87101, Definitions, that may result in harm to self or others, such as unsafe wandering, elopement, hallucinations, lacking in hazard awareness, or lacking in impulse control Continued on LIC809C.. Facility is to update the resident's care plan after the reappraisal as needed. R1's care plan shall meet resident's current needs, and all health & safety hazards need to be addressed in the care plan, ensuring sufficient staffing to meet these identified needs. Per record reviews, R1 does not reside in memory care, and staff are to ensure all resident's needs are met, including behavior of wandering away from the facility. R1 does have a wander-guard on their walker they use to ambulate but has continued to awol the facility without staff's knowledge and/or supervision. Per record review, The Department was not in receipt of R1’s AWOL incidents that occurred on 5/8/25 and 6/6/25; This is a required report, per regulations. The following deficiencies will be cited, LIC809D. 87463(g)(j) Reappraisals-The licensee shall ensure corresponding changes are made in the care and supervision provided to the resident. The licensee shall evaluate staffing needs to ensure that there is a sufficient number of direct care staff, as specified in Section 87411, Personnel Requirements – General, to support each resident's physical, social, emotional, safety and health care needs, as identified in their current appraisal. 87211(a)(1)-Reporting Requirements-Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The following deficiencies were cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation and/or Health & Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with the Administrator James Homer. Appeal rights provided.