Facility Evaluation Report

On 03/4/2026 at 9:00AM Licensing Program Analyst (LPA) A Gomez conducted an unannounced Case Management visit regarding a self-reported incident. LPA met with Executive Director (ED), Kiel Stromgren, and explained the purpose of the visit.

A self-reported incident report was received on 2/26/2026 from facility that indicated Resident 1 (R1) eloped from the facility on 2/24/2026. R1 is a memory care resident.

During the visit, LPA interviewed ED. ED states that on the day R1 eloped from the facility the alarm went off in memory care that the door had been activated. Staff assumed that a resident (R2) with a history of triggering the door had activated the alarm and when they checked and saw R2 was present they reset the alarm and did not follow proper procedure. ED states that staff should have done a head count and room inspection to ensure all residents were accounted for. Because this did not happen staff did not realize that R1 had eloped until police notified the facility that they had found one of their residents. According to incident report the alarm went off at at approximately 10:45pm and police notified the facility of finding a resident at approximately 11:20pm . ED states that they provided additional training to staff and a disciplinary action to S1.

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.

Exit interview conducted. Appeal Rights and a copy of this report provided.