Facility Evaluation Report

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Executive Director Christine Greenway and explained the reason for the visit. On May 8, 2026, the Agency received a special incident report (SIR) that Resident 1 (R1) left the facility unattended on May 2, 2026. On May 2, 2026 at 2:01 pm R1 left the facility for 20 minutes and returned. Staff reported that R1 was thought to be a visitor and allowed to leave the facility by mistake. Non-care staff were present when R1 left the facility. When R1 returned they were assessed by care staff and no injuries were noted. R1 was placed on 48 hour alert charting with increased checks upon return. R1's responsible party and primary care physician were notified. A review of records shows that R1's last doctor's visit was on April 27, 2026. R1's physician report dated June 5, 2024 states R1 cannot leave the facility unassisted. The Administrator reported that R1 is on increased checks and his care plan has been updated to include wandering behavior. Facility is responsible for R1 and the facility is a memory care facility. Staff verified R1 left the facility unattended. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.