On 09/07/2026, the Department received an incident report stating that on 09/07/2026 around 06:56 AM, Resident #1 (R1) eloped through the front door of the Memory Care Unit (MCU) while a staff member was entering. Staff noticed R1 missing around 07:04 AM, which then prompted staff to initiate the facility’s elopement procedures which included showing surrounding businesses R1’s picture. Around one (1) hour later at 8 AM, the facility received a call from Witness #1 (W1), a customer of a surrounding business, stating that R1 was seen across the street, 1.0 miles away from the facility. The Health and Services Director picked R1 up from that location and R1 was escorted back into the facility. R1 did not have any visible injuries or marks. The facility updated R1’s care plan to include a one-on-one private caregiver, alert charting and increased monitoring, and a Wanderguard tracking bracelet which will alert facility staff if R1 attempts to exit. Facility management also provided retraining and education to facility staff.

On 09/11/2026, the Department received an incident report stating that on 09/08/2026 around 10:14 PM, R1 eloped a second time from the facility using their loading dock door. Facility staff became aware of R1’s absence at approximately 10:30 PM. The facility initiated their elopement response measures which included calling 911 and having facility staff search the surrounding area. Authorities located R1 a little over one (1) hour later at approximately 11:35 PM. R1 did not have any visible injuries or marks. A one-on-one private caregiver for R1 was implemented, R1 was placed on alert charting and increased monitoring, and staff observed the Wanderguard bracelet to still be on R1. Report Continued on LIC809-C.

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

Lastly, on 09/16/2026, the Department received an SOC341 stating that a third-party private caregiver possibly handled Resident #2 (R2) in a rough manner. Facility management reviewed SafelyYou footage and observed the private caregiver attempting to redirect R2 by grabbing R2’s arm. Facility management reported the concern to the private caregiver’s agency and requested that the caregiver no longer return. The facility cross-reported to the Long-Term Care Ombudsman and R2’s responsible party.

During today’s visit, LPAs conducted a physical plant tour to ensure there are no health and safety hazards, conducted interviews with two (2) staff members, and reviewed and obtained copies of pertinent documents. At 12:12 PM, LPAs conducted a tour of the facility. LPAs observed R1 in their room and wearing a Wanderguard roam alert bracelet. No immediate health and safety hazards were observed or noted.

LPAs interviewed staff who stated that multiple measures have been implemented after R1’s elopements. R1 was relocated to an apartment that is further away from facility exits, a one-on-one private caregiver was put in place at the facility’s expense, and R1 and their responsible party consented to a Wanderguard bracelet which will alert facility staff if R1 gets close to any exterior exits.

LPAs reviewed R1’s physician’s report signed and dated 08/30/2026 which documents that R1 would be at risk if allowed to leave the facility unsupervised. Interviews confirmed that facility staff were unaware of R1’s exit-seeking behavior as R1 was a newer resident. R1 was admitted to the facility on 09/05/2026 and R1’s elopements occurred on 09/07/2026 and 09/08/2026. LPAs reviewed in-service training records documenting multiple trainings conducted with all staff on topics such as elopement response, elopement protocol, possible exit-seeking interventions, and resident checks from 08/27/2026-09/12/2026.

LPAs interviewed staff about R2’s incident and staff indicated that all agencies were made aware of the incident. Facility management reported the incident as a precautionary measure. It was unclear in the video footage if the private caregiver handled R2 in a rough manner, but management reported the incident to be safe. R2 relocated to another facility and the private caregiver was not stationed to return.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiency may result in civil penalties. An additional report may follow if warranted.

Exit interview conducted. Appeal rights and a copy of the report were provided.