Facility Evaluation Report

At approximately 9:00 AM, Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Case Management - Incident Visit and met with General Manager, William Phelps. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL).

CCL received an incident report on 04/28/2025. The report stated that on 04/25/2025, Resident (R1), who has a diagnosis of dementia and is unable to leave facility unassisted, eloped from community at approximately 7:20 PM, by exiting through side/delayed egress gate out of memory care courtyard as it had been unlocked by maintenance department, staff (S1) for landscaping and did not re-lock and the alarm never went off to alert care managers. At approximately 7:30 PM, R1 was observed by staff on their way to work, laying on the ground as emergency medical was arriving and transported R1 to hospital returning same night with minor injuries; PCP and family were notified. LPA was provided; staff signed training for elopements, plan to keep residents safe from future risk, and investigation documents.

Per R1’s Physician’s Report (LIC602) R1 is diagnosed with dementia and is unable to leave the facility unassisted. (Deficiency cited)

This is the 3 rd incident a resident has eloped from the memory care unity from facility: 1/30/2024 & from the memory care courtyard gate on 9/19/2024.

Civil Penalty for $500.00 was issued during today's visit for Zero Tolerance, Absence of Supervision.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.