Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Incident visit and met with Assistant Administrator Armando Guba.

The purpose of the visit was to respond to an Unusual Incident/Injury Report (IR) submitted by the facility to the department on 06/03/2025 regarding an incident that occurred on 06/02/2025. The IR stated that on 06/02/2025 at around 10:00 PM, staff observed that resident R1 had not returned to the facility. Staff checked inside and outside of the facility, but could not find R1. Facility staff filed a missing persons report with local law enforcement.

On 06/09/2025, LPA Chang called the facility and spoke with Assistant Administrator Guba, who stated that police had found R1 on the night of 06/08/2025. Assistant Administrator Guba stated R1 was staying at the hospital for further evaluation before returning to the facility. Assistant Administrator Guba submitted a copy of R1's Physician's Report, which states R1 is able to leave the facility unassisted.

During visit on 06/11/2025, LPA Marrufo interviewed Assistant Administrator Guba, who stated R1 is still at the hospital undergoing further evaluation before returning to the facility. Assistant Administrator Guba stated that on the morning after breakfast on 06/02/2025, R1 told staff R1 was going to go to the parking lot to get some fresh air. Staff do not require residents to sign out if they will be in the parking lot but not leaving facility grounds. R1 did not sign out. By 7:45 PM, staff began to notice that R1 was not present in the facility and began searching for R1 within the facility. By 10:00 PM, R1 had not been found and Assistant Administrator Guba instructed staff to file a missing persons report. No deficiencies were cited as per California Code of Regulations Title 22. This report was reviewed with Assistant Administrator Guba and a copy of this report was provided.