Facility Evaluation Report

At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Kimberly Humphrey, and Health and Wellness Director, Florence Van Heusden . The purpose of the visit was to follow up on incident reports that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 07/23/2025. Report stated that on 07/18/2025, facility staff witnessed Resident 1 (R1) exit the facility through the main door. Facility staff immediately followed R1 to redirect back to the facility but R1 refused. Facility staff followed R1 on foot and by car to the freeway. Facility contacted San Rafael Police Department and R1 was taken to the hospital for further evaluation. Facility made all notifications per regulation.

I ncident Report 2 : CCL received an incident report 07/30/2025. Report stated that on 07/26/2025, Resident 2 (R2) exited the facility through the main door and crossed the street. Staff Member 1 (S1) was outside with another resident's dog and observed R1 outside. S1 notified additional staff members for assistance and R1 was redirected back to the facility. Facility made all notifications per regulation.

LPA obtained additional documentation related to the incidents and copies of elopement training conducted on 07/31/2025 and 08/04/2025. *Deficiency issued today under Regulation 87705(d) has been cleared with Plan of Corrections letter provided during visit.

Deficiencies are 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) d ue date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, Plan of Corrections, Appeal Rights, and Plan of Corrections Letter discussed and provided to Executive Director. Signature on form confirms receipt of documents.