Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias conducted an unannounced case management visit to the facility to conduct a health and safety check for an incident that was reported to the Regional Office. LPA explained reason for visit and was greeted by staff on duty.

On October 13, 2025, the Regional Office received an incident report of elopement with the incident occurring for October 05, 2025 for resident 1 (R1). R1 exited the facility at approximately 10:34am on that day. Staff was made aware R1 was not at the facility and initiated search and safety protocols at 11:30am. R1 was located by local law enforcement and brought back to the facility at approximately 3:30pm the same day.

The facility's main entry and exit door is in the process of repair and has partial functionality. Temporary measures haven taken place to alert staff when the door is open including an audible alarm that will alert every time the door is open regardless if the door is armed. LPA tested the egress function and it is operational. The facility held in-service training for staff on September 9, 2025, October 3, 2025, and October 6, 2025 on updated protocols for elopements. Facility provided updated elopement policy along with R1's records to LPA. Executive Director Melvin Galloway stated the facility will complete an ongoing remodel by mid November which includes replacing the main door's electronics to restore full functionality. LPA toured the facility and observed no health or safety concerns.

Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.