Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection related to several incident reports (LIC624) recently submitted to the Department. LPA met with Anelise Fusneica, Assistant Administrator and stated the reason for the inspection. LPA later met with Monica Avalos, Health and Services (HSD) Director to discuss each incident report. The facility is a licensed for individuals who have a diagnosis of Dementia. LPA observed several residents, including (R1) ambulating with staff in the common areas.

Resident (R1) exited through the front entrance on July 16, 2026 (2:26 pm) and staff immediately responded after hearing the door alarm. (R1) was located in the facility parking lot. On July 19, 2026 (1:30 pm) from the back door and located (5) minutes later in the parking lot. (R1) did not sustain any visible injuries after each incident. HSD stated that (R1's) medication, Valproic Acid/Depakote was decreased on June 28, 2026 and a week later, (R1) began showing increased aggression and exit seeking behaviors. On July 13, 2026, the HSD and family member discussed increasing the Depakota medication with the physician back to three times daily, and it was. (R1's) aggression has improved already but they are still showing some exit-seeking behaviors, until the new medication dosage takes full effect.

LPA observed (R1) trying to exit, alongside a staff member, during today's inspection. The HSD expects the exit seeking behaviors to improve within the next week. (R1) understands how to open the doors but staff offices are near the front door, and the medication room is near the back door.

Resident (R2) was sent to Emergency Room by home health medical staff on July 21, 2026 due to being confused, lethargic and showing a low heart rate. Lab work was done and (R2's) medications were evaluated with the Depakote dosage being decreased. (R2) returned to the community today, July 23, 2026.