Incident investigation·October 23, 2025

Licensing Program Analyst (LPA) Hansen was at facility delivering complaint findings and conduct a Case Management - Incident Visit and met with Administrator, John Beltz. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL). CCL received an incident report on 10/16/2025. The report stated that on 10/10/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community. Staff conducted resident count at approximately 5:15 PM, not locating R1. At approximately 5:35 PM, RCD had been driving around adjacent housing community looking for R1, observed R1 speaking with 2 police & 2 bystanders who had called police. RCD escorted R1 back to community; PCP and family were notified. R1 was assessed at facility, no injuries sustained. During today's visit, it was revealed to LPA that R1 had been in the bistro participating in activities prior to dinner and when activity ended, groups of residents, staff, and others left the area to go to dining area, back to memory unity, and to leave, and R1 had gotten out of facility by the front door, unbeknownst to anyone. The same situation took place with another resident of the memory care unit on 5/3/2025. Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited) *****Civil Penalty for $1,000.00 was issued during today's visit for repeat of citation of 87411(a), previous citation given on 5/3/2025 for Zero tolerance. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided