Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for a deficiency issued on March 6, 2025 during the required annual inspection. LPA was greeted and granted entry by staff and discussed the purpose of the inspection.

Administrator Emma Han provided training logs for four out of four staff. The Plan of Corrections has been fulfilled by the assigned POC due date of March 27, 2025, thus clearing the Type B deficiency HSC 1569.625(b)(2).

During the POC visit, LPA toured the facility with staff. LPA observed the refrigerator in the kitchen locked using a bike lock. Staff stated resident 1 (R1) has dementia and opens the refrigerator door often and eats from there. LPA toured the exterior of the facility. LPA observed wood planks blocking three exit doors in the rear of the facility, preventing the doors from opening from the inside. LPA observed a double cylinder deadbolt installed on the front door, preventing exiting through the door unless a key is used to open the door. Three out of three staff stated the measures were taken due to R1's wandering behaviors. LPA captured images. LPA interviews with two out of three staff stated R1 has eloped the facility twice in the past. LIC500 personnel report shows one staff one duty per shift.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An immediate civil penalty for $500 is being assessed. See LIC421IM. This report was discussed with the facility representative and a copy was provided along with appeal rights.