Incident investigation·March 2, 2026

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management - incident visit and met with Edgar Bravo, Dining Services Director. The purpose of this case management inspection is to follow up on a self-report incident report submit to Community Care Licensing (CCL) on 02/17/2026. CCL received a self-report incident report on 02/17/2026 reporting an incident that occurred on 02/10/2026 at approximately 6am. Resident (R1) left their apartment using their walker, R1 exited through front egress doors into lobby, then exited through front lobby door, until they were found on the sidewalk in front of the community by a member of staff within 20 minutes of leaving. R1 said that they were waiting for a ride. R1 was escorted back into the community. R1 was assessed by staff and there were no injuries. During today’s visit, LPA learned that the incident happened while the staff was doing the cross over shift and there was no staff supervising the residents. Per Dining Services Director, the facility implemented a preventive measure to maintain at least one staff inside memory care unit during the shift change meeting. LPA also reviewed R1’s physician report (LIC 602) dated 3/24/2019, care plan indicates that R1 has been added to the monitor alert chart, in-service training records confirmed that staff held a training session on 2/18/26 including elopement drill documentation tool, which is included to the facility elopement procedures. Alarm book is documenting inspection dates and times when the checks are been performed. Facility Policies and Procedures regarding AWOL/Elopement were not followed. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted with Dining Service Director and copy of this report was given.