Facility Evaluation Report

On November 12, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case- management visit in relation to an incident that occurred on 9/24/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit.

The Licensee reported on September 24, 2025 at around 7:00pm, the police officers arrived to the facility with Resident 1 (R1). Licensee indicated R1 was found a block away from the facility and staff are unaware how R1 was able to leave unseen. When staff made rounds at 6:30pm, R1 was observed in his/her room.

During the visit today, LPA interviewed assistant administrator, reviewed R1's file, and toured the facility to check the exit door alarms. LPA checked 5 exit doors on the first floor; of which 2 did not have alarms (including front door), 2 were off but working, 1 was working, and 1 that requires replacement. The exit door on the ramp was observed working but turned off. LPA checked 4 exit doors on the second floor, of which 3 were observed working, 1 observed not to have an alarm at all. Based on R1's physician report reviewed dated 12/21/24, R1 has dementia, is confused, disoriented, and unable to leave the facility unassisted. Although R1's physician's report indicated R1 does not have a wandering behavior, based on R1's reappraisal dated, 12/5/25, the facility noted R1 to be a wanderer and is confused and forgetful.

According to the assistant administrator and the staff schedule reviewed from September 24, 2025, there were 3 caregivers on the first floor, 2 caregivers on the second floor and 1 med-tech throughout the entire facility during PM shift on 9/24/25. The assistant administrator indicated the staff did not see R1 elope from the facility. According to the assistant administrator and observations, the front entrance door does not have any locks or alarms and is unlocked 24/7. (continue to 809C).