Facility Evaluation Report

Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection. LPA arrived to the facility and met with Annette Cutcomb, Site Coordinator. The purpose of this case management inspection is to follow up on a self-report incident report submit to Community Care Licensing (CCL).

CCL received a self-reported incident report on 4/15/2026 reporting an incident that occurred on 4/15/2026 about 11:20am involving participant P1, who went AWOL while part of day program group traveled to terrace with staff and site coordinator remained with other members of group in program room. A different senior center class was exiting at the same time, when P1 followed the class as they made their exit from the building, then P1 traveled across two driveways and entered the library next door. Site coordinator alerted staff and the front desk/full staff at the senior center, then called 911. Staff went outside, located P1 at the library, they re-directed P1 back to the program. Site coordinator cancelled the emergency response request and contacted the Program Manager to report the incident. During today’s visit, LPA learned that staff have implement preventive measures: staff will plan to wait for other groups to have cleared passageways prior to moving day program participants. Program Manager will conduct elopement training with all staff. Facilities Polices and Procedure regarding AWOL/Elopement were not followed. LPA reviewed P1’s physician report and needs care plans to confirm that P1 has a diagnosis of dementia. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given. Exit interview conducted with site coordinator and copy of this report was given.