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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200873
Report Date: 05/29/2026
Date Signed: 05/29/2026 03:46:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/26/2026 and conducted by Evaluator David Doidge
COMPLAINT CONTROL NUMBER: 15-AS-20260526173431
FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:REDDY, ANNAFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: 116DATE:
05/29/2026
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Executive Director Anna ReddyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent resident from wandering from the facility
INVESTIGATION FINDINGS:
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On 05/29/2026 at 10:45 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct an initial 10-day complaint investigation and to deliver findings regarding the allegation above. LPA met with Executive Director Anna Reddy and explained the purpose of the visit.

During the course of the investigation, LPAs obtained copies of the Physician’s Reports, Appraisals Needs and Services for one resident. LPAs also interviewed S1, S2 and R1.

Allegation: Staff did not prevent resident from wandering from the facility

Investigation Findings: It was reported to the department that around 5 PM on Mat 22nd, staff could not find a R1 in the facility. R1 is in the memory care unit and cannot leave the facility unassisted, as verified by R1’s Physician’s report.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20260526173431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 05/29/2026
NARRATIVE
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Continued from LIC9099

S1 informed LPA that S1 was not in the facility at the time of the elopement and referred LPA to S2 for more information. S2 stated that S2’s had already gone home for the day when staff called to inform S2 of the elopement of R1. 911 was called before S2 returned to the facility, and S2 notified the responsible parties upon return to the facility. R1 had been given a tracking device by R1’s family members, as confirmed by R1’s responsible party, and the family used the device to locate R1 and direct the police to R1’s location. R1 was returned to the facility and evaluated by staff and later a physician with no health or physical issues. S2 informed LPA that a staff member was in the memory care unit delivering food and held the door open for R1 thinking that R1 was not a memory care resident. R1 proceeded down the elevator and walked out the front door. S2 reviewed security cameras and saw that at the time of R1 elopement, a group of visitors had all walked out together, making it difficult for the concierge to see R1. S2 informed LPA that food prep staff had been given key fobs to access the memory care unit to ease the delivering of meals. The food staff member was not familiar with any of the memory care residents and simply mistook the resident for a visitor. Based on interviews conducted the above allegation is SUBSTANTIATED.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Deficiency is cited from Title 22 California Code of Regulations (see LIC9099D). Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in an additional civil penalty.

Deficiency and plan and proof of correction were discussed with Executive Director Anna Reddy

Exit interview conducted, Appeal Rights, and a copy this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260526173431
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2026
Section Cited
CCR
87411(a)
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Personnel Requirements - General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidence by:
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The facility has already address this issue and made changes to help prevent further elopements. Memory Care director has taken the key fobs away from non memory care staff and given an in-service training to all staff
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Based on record review and interviews, licensee did not comply with the section cited above by having resident leave the facility unassisted which poses a potential health and safety risk to the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: David Doidge
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2026
LIC9099 (FAS) - (06/04)
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