Facility Evaluation Report

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on incident reports received by the department. LPA was greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 04/11/2025 indicated Resident 1 (R1) was observed to be missing in the facility around 11:45 AM. Facility initiated search. Resident was located outside the community on the corner by a visiting Nurse Practitioner. Resident was assessed to be without injury. Facility investigation determined the resident had gone out an exit gate not normally used by staff. Due to ongoing construction, staff had used the gate which may not have been properly locked. The resident was determined to be out of the facility for approximately 15 minutes.

Incident report dated 04/13/2025 indicated the resident had a witnessed fall in the courtyard. Resident complained of shoulder pain and was sent out where shoulder was popped back in place at the hospital. No further concerns with shoulder noted.

Per physician report dated 10/18/2024, R1 is diagnosed with Mild Cognitive Impairment and is not allowed to leave the facility unassisted.

Facility re-assessed resident and is on frequent checks when not in common area.

LPA spoke with R1 during the visit. Resident appeared clean and well taken care of.

Based on the observations made during today’s visit, 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 as well as appeal rights.