Facility Evaluation Report

On 04/09/2025 at 10:45 AM, Licensing Program Analysts (LPAs) P.Manalo and K. Nguyen conducted an unannounced Case Management visit regarding a self-reported incident that occured on 03/22/2025. Administrator self-reported the incident on 04/07/2025. LPAs met with Administrator, Samuel Tet, and explained the purpose of the visit.

LPAs received a self-reported incident report from the facility that indicated that Resident 1 (R1) went AWOL and was found by the neighbor. The neighbor contacted the police, and R1 was escorted back to the facility by the police. The facility did call 911 when the incident occured.

During the visit, LPAs reviewed R1's Physician's Report dated 10/04/2024 that indicated that R1 has a diagnosis of Mild Cognitive Impairment and is unable to leave the facility unassisted. Upon waiting for the Administrator to arrive, LPAs observed one staff caring for 6 residents at one time during the visit. LPAs observed Staff 1 (S1) go into the staff room leaving the residents unattended.

Based on interview, Administrator stated that he doesn't think that the alarm was working at that time. Administrator confirmed with LPAs while reviewing the Ring Camera, there was no indication of the resident leaving the facility due to the alarm system not operating properly.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiency within a 12-month period may result in civil penalty.

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