Facility Evaluation Report

Licensing Program Analyst (LPA) Nakagawa arrived to conduct a case management visit regarding an incident report submitted to Community Care Licensing (CCL) for R1 which occurred on 10/03/2025. LPA met with Luceli Soto-Luis, the newly appointed Administrator.

R1 eloped while under facility responsibility. Resident R1 has a physician's report dated 02/22/2024 diagnostic of dementia which states that resident is NOT able to leave facility unassisted at any time. Per facility staff resident R1 was found by family member of staff on sidewalk in community and returned to facility; staff were unaware that R1 had eloped.

Due to this incident, immediate elopement training for staff will be held, the front gate will be repaired, new walky-talky protocols will be established. Additionally, a wander-guard system is being considered for installation.

The following deficiency was 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. Appeal of Rights Given.