Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management Visit and met with Administrator (ADM) Sharon Basa. The purpose of the visit was to follow up on an incident reported by the facility via Unusual Incident/Injury Report (IR) on 03/05/2026.

The incident involved resident R1 eloping from the facility on 03/04/2026 at 5:47 AM. When R1 eloped from the facility, a staff attempted to pursue R1, but could not maintain constant line of sight with R1. Another staff pursued R1. At approximately 06:16 AM, staff were able to put R1 into the facility van and return R1 to the facility. Along with the IR, the facility submitted R1's Physician's Report, which states the resident is unable to leave the facility without supervision.

During visit on 05/13/2026, LPA Marrufo obtained a copy of R1's Appraisal/Needs and Services Plan, which states R1, "...requires 1:1 staff supervision during waking hours."

During visit on 05/13/2026, LPA Marrufo interviewed ADM. During interview, ADM stated that R1 usually wakes up around 6:00 AM. ADM stated she has attempted to hire a 1:1 staff for R1, but due to R1's behaviors, it has been difficult to keep a 1:1 staff. ADM stated there are two staff that R1 will listen to and ADM keeps at least one of those staff on shift for R1.

An Advisory Note was issued. See LIC9102 for more information. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with ADM Sharon Basa and a copy of this report was provided.