Facility Evaluation Report

At approximately 11:40AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit, and met with Staff Member, Tigist Dinka. Administrator, Martha Ghezzehai, arrived during visit at approximately 1:50PM. The purpose of the visit was to follow up on a self-reported incident report that was submitted to the Santa Rosa Regional Office (SRRO).

Incident Report 1: The SRRO received a report on 12/22/2025. Report stated that on 12/19/2025, Resident 1 (R1) left the facility. Per report, the night-time caregiver was providing care to another resident when R1 left the facility. Facility notified San Rafael Police Department (SRPD) and Fire Department. R1 was found down the street from the facility by SRPD. R1 was sent to the hospital for further evaluation as it was observed R1 had a fall. Facility made all appropriate notifications per regulation.

Review of R1's medical assessment dated 10/05/2025 does not indicate if they have a diagnosis of dementia and stated they can to leave the facility unassisted. Review of R1's care plan dated 12/07/2025 indicated that R1 had a diagnosis of dementia. Review of R1's medical assessment dated 02/20/2026, states that R1 has a diagnosis of dementia and is unable to leave unassisted. There was no updated care plan to reflect R1's new medical assessment from February 2026. Review of documents showed that facility conducted elopement training on 12/20/2025.

LPA discussed with Administrator on ensuring that resident documents are filled out correctly and are updated to reflect their care needs as required. Per Administrator, R1 is scheduled for a new medical assessment at the end of the month. Administrator to submit updated paperwork to Community Care Licensing (CCL) as part of their plan of correction.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights, discussed and provided to Administrator. Signature on form confirms receipt of documents.