Facility Evaluation Report

A Non-Compliance conference was conducted on 12/22/2025 at Sacramento North Regional Office via Microsoft Teams. Present in the meeting were facility’s representatives Mary Roberts, Operating Officer, Administrator Cathy Dustin, Acting Regional Manager (RM), Laura Munoz, Licensing Program Manager (LPM), Troy Ordonez and Licensing Program Analyst (LPA), Graham Gunby. Department reviewed the purpose of the NCC, emphasizing the responsibility of the Licensee to ensure the health, safety, and personal rights of residents in care and to maintain substantial compliance with applicable licensing laws and regulations. The Department discussed the facility’s compliance history, including a substantiated complaint in which staff failed to prevent a resident from leaving the facility unassisted, resulting in citations and civil penalties. The Department noted that the appeal of the citation was denied.

The Department identified the following areas of concern requiring corrective action submitted by 01/22/2026

· Acceptance and retention of residents with elopement or exit seeking behaviors beyond the facility’s ability to safely supervise.

· Failure to consistently update residents Needs and Services Plans and reappraisals to reflect changes in condition.

· Insufficient staff training related to elopement risk, exit-seeking behaviors, and supervision requirements.

· Administrator oversight, accountability, and fulfillment of required duties.

· Improper use, adjustment, or deactivation of door alarms intended to monitor resident movement.