Facility Evaluation Report

On 8/15/25 at 11:10 AM, Licensing Program Analyst (LPA) J. Clancy-Czuleger conducted a case management visit as a result of an elopement that occurred on 6/25/2025. LPA met with Executive Director David Clawson and explained the purpose of the visit.

While at the facility on an unrelated incident LPA was made aware that R1 had eloped from the facility on 6/04/2025, 6/15/2025, 6/21/2025 and that R2 had eloped from the facility on 8/09/2025. Both R1 and R2 are memory care residents. All egress doors were operational at the time of elopements.

On 08/09/2025 at around 1:30 pm, R2 stepped out of community and fell while walking. Paramedics were called and brought resident to John Muir Hospital for evaluation. Resident Came back next day, Concord Police, and R2's family were notified.

On 6/21/25 staff reported that R1 was out on the street and was Immediately assisted and redirected back to the community. On 6/15/25 at approx. 7:45pm R1 was observed wandering outside of the building. Resident aide assisted resident back inside the building. On 6/04/25 staff reported that the memory care door alarm was on and R1 was out in the parking lot and was redirected back to memory care.

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.