Incident investigation·March 5, 2026

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Administrator (Admin) Wendy Cornejo. On 2/9/26 CCL received an Incident report from facility indicating resident (R1) eloped from the facility. R1 was observed walking along the vineyard area on the side of the facility. R1 became disoriented and thought they could walk behind the facility. As R1 was walking, they realized they were no longer at the facility. R1 waved down a neighbor who was driving by and that neighbor helped R1 back into the facility the same day. R1 was unharmed and facility notified R1’s responsible party and R1’s doctor. Per Administrator, and LPA observation, residents often utilize the rocking chairs outside in front of the facility to enjoy the sunshine and fresh air. These chairs are visible to both the concierge and from the Administrator's office inside the facility. Due to this incident, Administrator will work with upper management to install a gate to the entrance of the facility so that residents can still enjoy a walk through the vineyard located on the side of the facility. Additionally, facility is located off a busy road, especially during high traffic hours. Administrator advised that until the gate is approved and installed, residents will now be utilizing only the interior gardens in which to walk and enjoy the outdoors. Per R1’s physician’s report, R1 is not allowed to leave the facility unassisted. Upon LPA arrival, Admin advised LPA of a recent elopement 2/28/26. New resident (R2) had just moved in the night before later in the evening. On the morning of 3/1/26, R2 had a disagreement with their family member for moving them here and took off walking outside. Later n the morning around 9:30am resident's responsible party noticed they were not in their room, All available staff immediately initiated a search of the building including the courtyard, rose garden, memory care unit, restrooms, and all apartments. At around 9:45am, Health and Wellness Director (HWD) contacted the Administrator to review the front door security cameras. Around 10:00am, the front desk received a call from the fire department advising Continued on 809C... Continued from 809... that they located R2 down the street The fire department and paramedics spoke directly with R2's responsible party and they proceeded to pick up the resident. Per R2's physician's report R2 is not allowed to leave the facility unassisted. ( deficiency cited, see 809D ) Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. 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 Administrator and a copy of this report was given.