Facility Evaluation Report

While at the facility investigating a complaint (Control # 15-AS-20251021141652) and upon interviews and review of the Department's incident reports for the facility, Licensing Program Analyst (LPA) Delmundo learned that the facility did not report the incident that occurred on 10/18/25 between residents, R1 and R2, to appropriate agencies.

Review of R1 records showed R1 has major neuro cognitive disorder, can not leave the facility unassisted, has wandering and sundowning behaviors. Executive Director (ED) Jeff Sumabat stated when R1 and R2 moved-in, a wander guard was issued for R1; however, during interview, LPA observed R1 without wander guard. ED also stated that care conference was conducted with the residents' family and medical provider, however, R1 was resisting care and a personal companion which was placed in December 2024 for R1 was discontinued in March 2025 by the family. LPA learned that service plan was not updated accordingly after the incident happened on 10/18/25.

Review of R2's Physician's Report dated 9/10/25 revealed R2 needed assistance with medications including administration of injection and R2's Care Plan was also not updated to reflect the change.

Deficiencies cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation may result in civil penalty.

Deficiencies and plan and proof of corrections were discussed with ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.