Incident investigation·June 15, 2026

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct this Case Management Visit to follow up on incident report submitted to CCL. LPA met with Administrative assistant Lisa DiBartolo. Incident Report (SIR) was received on 6/11/26. According to SIR, on 6/5/26 resident (R1) at approximately 8:10 a.m, R1 exited the facility through the front gate while a visitor was entering, Staff became aware the resident was no longer on the premises and immediately initiated a search of the facility and surrounding area. At approximately 8:31 a.m, Sonoma County Sheriff's Office notified the facility that the resident had been located. R1 was assessed by EMS, no injuries were identified, and R1 returned to the facility. Administrator notified responsible party as required. R1 is currently being monitored for safety and well being. Facility is actively researching and evaluating technological solutions that may provide staff notification when residents identified as being at risk for elopement approach exit points. Any solution implemented will be consistent with Title 22 requirements, resident rights, and the resident's assessed needs. Warning signs are posted on both sides of the front gate instructing visitors to ensure that no resident exits the facility through the gate with them unless authorized and accompanied by staff. Staff were given specific instructions to watch the resident of elopement risk at all times. During today's visit, LPA requested and reviewed R1's records including their physician report (LIC602), care plan and facility elopement policy. Per R1's physician report dated 2/15/24, R1 does not have a diagnosis of dementia, R1 is able to leave the facility unassisted and communicate their needs. R1's care plan dated 6/6/26 has been updated to indicate exit seeking behaviors, but it has not been signed by R1's responsible party. LPA reviewed the facility elopement policy, which determines that the facility staff followed their policies and procedures regarding AWOL/Elopement including the identification of risk for each resident after any significant change in condition. No deficiencies found during today's visit. Exit interview conducted with administrative assistant and copy of this report was given.