Facility Evaluation Report

On 11/5/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit to deliver the investigation outcome of an incident that was reported by the facility. LPA met with administrator and explained the purpose of the visit.

On 9/9/2025, the facility reported that at around 7:30AM, staff #1(S1) heard the auditory device on the downstairs door went off but S1 did not physically check the alarm because S1 thought the alarm was triggered by resident #1 (R1) who went to the garage. A few moments later, (S1) discovered R1 was missing and reported it to the House Manager who was on her way to the facility.

The House Manager looked for R1 around the facility and found R1 walking around at the local elementary school accompanied by the school nurse. The house manager brought R1 back to the facility.

On 9/10/2025, LPA conducted a case management visit to obtain additional information concerning the incident and during the visit, LPA observed the auditory devices on the sliding door in the kitchen, the door to the garage and the door to the back were malfunctioned ( the facility was cited on the same day, see LIC 809 and LIC 809 D).

LPA interviewed (S1) who stated that on 9/9/2025 at 7:20AM - 7:25 AM, she was working by herself and when she noticed R1 was not around the facility, she started searching the entire facility and observed the latch on the gate by the garage was open so she immediate reported it to the house manager. However, she did not know exactly which exit R1 took to leave the facility as she was caring for the other residents.