Incident investigation·September 26, 2025

At approximately 1:30 PM, Licensing Program Analyst (LPA) Nakagawa arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Maria Burton. The purpose of the visit was to follow up on self-reported incident that were submitted to Community Care Licensing (CCL). CCL received an incident report on 07/18/2025. Review of the report stated that on 07/13/2025 Resident 1 (R1) left the facility unattended and was found by a bystander off the University Retirement Community (URC) campus who stated, according to the Incident Report, that R1 appeared to be lost. R1 asked the bystander to take him back to facility who brought R1 back and notified staff. R1's Physician's Report at the time of the incident stated that R1 is unable to leave the facility unattended. R1 has, since the incident, been re-assessed and new Physician's Report now states R1 may leave facility unattended. Due to staff being unaware of and/or unfamiliar with R1's restriction to leave facility unattended R1 was able to leave URC without supervision. Deficiency cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator and Appeal rights were given.