Incident investigation·June 10, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management visit and met with Tristan Amari, Business Office Manager (BOM). On 5/14/25 CCL received an Incident Report for resident R1. Incident report indicated that when staff was arriving to work for their shift they found R1 next door to facility in the Wells Fargo parking lot walking around by themselves. Staff accompanied R1 back to facility. R1 was assessed for injury and was found to be without an injury as well as appropriately dressed. LPA reviewed Physician's Report and Care Plan for R1. Per R1's physician's report, R1 is not able to leave the facility unassisted. Per R1's care plan, R1 is a wandering/elopement risk. Per Jody Livingston, Health and Wellness Director, R1 had a Wander Guard that was found to be not working. Facility contacted Wander Guard and ordered "activation wands" to be overnighted to facility. Additionally, after the incident of elopement on 5/14 facility provided 1:1 care for R1 when private caregiver or family was not present. However, as of today, per HWD, R1 is no longer a resident at the facility. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with BOM. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with BOM and a copy of this report was given .